Investigation of abdominal masses (surgical tutor)
Physical signs of abdominal masses
Signs of hepatomegaly
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Mass descending below right costal margin and costal angle
 Moves with respiration and can not get above it
Dullness to percussion up to the level of the 8th rib in the mid-axillary line
Signs of splenomegaly
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Mass descending below the left 10th rib and enlarging in a line towards the umbilicus
Often has a palpable notch on the medial border
 Moves with respiration and can not get above it
Dullness to percussion
Can be brought forward by lifting the lower ribs
Can not be felt bimanually or balloted
Signs of a renal mass
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Mass lies in paracolic gutter
Moves with respiration but usually only lower border is palpable
Can be felt bimanually or balloted
Not dull to percussion
Signs of an enlarged gallbladder
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Mass arising from below the tip of the right 9th rib
Smooth and hemi-ovoid in shape
Moves with respiration
Dull to percussion
Can not feel space between mass and liver
Signs of an enlarged urinary bladder
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Hemi-ovoid smooth mass arising from the pelvis
Can extend above umbilicus
Non-mobile and dull to percussion
Does not bulge into the pelvis
Can not be felt on rectal examination
Signs of an ovarian cyst
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Smooth mass arising from the pelvis
Mobile from side-to-side but not up and down
Dull to percussion
Palpable fluid thrill
Lower extremity can be felt on pelvic examination
Causes of hepatomegaly
Smooth generalised enlargement
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Congestion due to cardiac failure
Micronodular cirrhosis
Reticuloses
Hepatic vein obstruction (Budd-Chiari syndrome)
Infective hepatitis
Cholangitis
Portal pyaemia
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Amyloidosis
Knobbly generalised enlargement
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Secondary carcinoma
Macronodular cirrhosis
Polycystic disease
Localised swelling
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Riedel's lobe
Hydatid cyst
Liver abscess
Hepatocellular carcinoma
Causes of splenomegaly
Infection
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Bacterial - typhoid, typhus, TB
Viral - glandular fever
Protozoal - malaria, kala-azar
Cellular proliferation
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Myeloid and lymphatic leukaemia
Pernicious anaemia
Polycythaemia rubra vera
Spherocytosis
Thrombocytopenia purpura
Myelosclerosis
Congestion
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Portal hypertension
Hepatic vein obstruction
Congestive heart failure
Others
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Amyloidosis
Gaucher's disease
Felty's syndrome
Angioma
Lymphosarcoma
Causes of a renal mass
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Hydronephrosis
Pyonephrosis
Perinephric abscess
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Hypernephroma
Nephroblastoma
Solitary cyst
Polycystic disease
Causes of a palpable gall bladder
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Obstruction of the cystic duct
o Stone in Hartmann's pouch
o Cholangiocarcinoma
Obstruction of the common bile duct
o Stone in common bile duct
o Carcinoma of the head of the pancreas
Courvoisier's law
'If in the presence of jaundice the gallbladder is palpable, the obstruction of the bile duct causing the jaundice is unlikely
due to a stone.'
Stones causes a thickened non-distensible gall bladder
Causes of a right iliac fossa mass
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Appendicitis
Tuberculosis
Carcinoma of the caecum
Crohn's disease
Iliac lymphadenopathy
Psoas abscess
Investigation of abdominal pain
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Emergency admissions account for 50% of general surgical work load
50% of emergency admissions are for abdominal pain
Conditions presenting with acute abdominal pain
Condition
Percentage
Non-specific abdominal pain
35
Acute appendicitis
17
Intestinal obstruction
15
Urological causes
6
Gallstone disease
5
Colonic diverticular disease
4
Abdominal trauma
3
Abdominal malignancy
3
Perforated peptic ulcer
3
Pancreatitis
2
Ruptured AAA
<1
Inflammatory bowel disease
<1
Gastroenteritis
<1
Mesenteric ischaemia
<1
Causes of non-specific abdominal pain
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Viral infections
Bacterial gastroenteritis
Worm infestations
Irritable bowel syndrome
Gynaecological causes
Psychosomatic pain
Abdominal wall pain
o Iatrogenic peripheral nerve injuries
o Hernia
o Myofascial pain syndrome
o Rib tip syndrome
o Nerve root pain
o Rectus sheath haematoma