Seminar 7 Course 6 Module IIC
The reformed curriculum, Third Faculty of Medicine
Prof. Jiří Horák
Palpable mass in the abdomen
Finding of a palpable mass in the abdomen always means a potentially important
clinical problem. The seminar deals with the most common causes, which may
underlay an abdominal mass.
1. The liver
Normally-sized liver crosses the costal margin in the right mid-clavicular line and its
craniocaudal projection on the abdominal wall does not exceed 13 cm. Liver
enlargement (hepatomegaly) may be a sequel of a large majority of hepatobiliary
diseases, e.g.:
- acute and chronic hepatitis, liver cirrhosis,
- steatosis, amyloidosis, glycogenosis etc.,
- toxic liver lesions,
- alcoholic liver disease,
- inborn errors of metabolism (hemochromatosis, Wilson's disease, some types of
porphyrias, alpha-1 antitrypsin deficiency),
- circulation disorders
venoocclusive disease),
(congestive
heart
disease,
Budd-Chiari
syndrome,
- liver inflitration by pathologic cells in hematologic malignancies,
- primary and secondary liver tumours,
- cholestasis and cholangitis.
2. The gallbladder
A healthy gallblader cannot be palpated. Gallbladder enlargement may appear in the
following situations:
acute cholecystitis. About 90% of cases are caused by a stone - acute calculous
cholecystitis.
Pathogenesis: stone entrapment in the gallbladder neck - chemical irritation and
inflammation of the gallbladderr wall - mucosal phospholipase splits lecithin to
lysolecithin - toxic damage of gallbladder mucosa. Mucinous layer with high
glycoprotein content is damaged - the mucosa is exposed to detergent action of bile
acids. In the gallbladder mucosa, prostaglandins are liberated that contribute to
inflammation of the mucosa and gallbladder wall. Blood flow to the gallbladder wall
decreases. These events occur under sterile conditions, bacterial contamination
develops later.
The gallbladder wall is edematous and of changed colour, the bile is turbid with
admixture of fibrin, blood and pus.
A gallbladder containing mainly pus is call empyema. In gangrenous cholecystitis the
gallbladder wall is necrotic withminute perforations.
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Seminar 7 Course 6 Module IIC
The reformed curriculum, Third Faculty of Medicine
Prof. Jiří Horák
Acute acalculous cholecystitis
It occurs mainly in the following conditions:
-
severe trauma,
-
large burns,
-
conditions after major surgery outside of the hepatobiliary area,
-
multiple organ failure,
-
sepsis,
-
long-term parenteral nutrition,
-
following the delivery.
Less painful forms come about in systemic vasculitis, general atherosclerosis and
AIDS.
Pathogenesis: the main role plays an ischemic lesion of the gallbladder wall, to which
the following factors contribute:
- dehydration,
- repeated blood transfusions with the subsequent overproduction of bile pigments,
- accumulation of viscous bile and mucus resulting in a stone-free cystic duct
obstruction,
- inflammation and edema of the gallbladder with impaired blood-flow,
- bacterial contamination of the bile with lysolecthin production.
Clinical presentation of acute acalculous cholecystitis is the same as in calculous
cholecystitis but it is frequently masked by the symptoms of the underlying disease.
Physical findings:
An inflamed gallbladder may be palpable as an ovoid mass, sometimes reaching
below the umbilicus, in other patients only the fundus is palpable. In case of
pericholecystitis with localized peritonitis a larger inflammatory mass may be
palpable. In slight cases the gallbladder cannot be palpated and we find only the
Murphy's sign.
In chronic cholecystitits, the gallbladder is usually small, retracted and non-palpable.
Non-inflammatory gallbladder dilatation
It occurs in tumours of the head of the pancreas and distal choledochus (the
Courvoisier's sign). The gallbladder is dilated due to the secretory pressure of the bile
in biliary obstruction. Palpation is non-tender.
Tumours of the gallbladder
Gallbladder carcinoma arises usually in chronic cholecystitis and usually is palpable
only when it infiltrates the adjacent liver parenchyma.
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Seminar 7 Course 6 Module IIC
The reformed curriculum, Third Faculty of Medicine
Prof. Jiří Horák
3. The stomach
Under normal circumstances the stomach is not palpable or otherwise amenable to
physical examination. A large gastric tumour or a dilated stomach filled with fluid as
in gastroparesis, pylorostenosis etc. may be palpable. Rarely, we can palpate a
stomach filled with condensed food or hairs (bezoar, trichobezoar).
4. The pancreas
Pancreas is located in the retroperitoneum and normally it is not amenable to physical
examination. However, it can be palpated under the following circumstances:
- pancreatic carcinoma,
- pseudocyst of the pancreas, arising as a sequel of an acute pancreatitis,
- a genuine pancreatic cyst (rarely).
5. The spleen
A normal spleen is not palpable and it weighs about 150 g. If a spleen can be palpated
it means that it is enlarged markedly. The main causes of splenomegaly are as
follows:
- infectious diseases:
- bacterial endocarditis and sepsis,
- infection mononucleosis,
- tuberculosis,
- typhus,
- brucellosis,
- cyomegalovirus infection,
- syphilis,
- malaria,
- histoplasmosis,
- toxoplasmosis,
- kala-azar,
- trypanosomiasis,
- schistosomiasis,
- leishmaniosis,
- echinococcosis,
- congestive splenomegaly in portal hypertension,
- spleen infiltration by malignant cells:
- Hodgkin's disease,
- non-Hodgkin lymphomas,
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Seminar 7 Course 6 Module IIC
The reformed curriculum, Third Faculty of Medicine
Prof. Jiří Horák
- multiple myeloma,
- histiocytosis,
- myeloproliferative syndromes (chronic myeloid leukemia, polycythemia
vera, myeloid metaplasia with myelofibrosis - extramedullar hematopoiesis),
- chronic lymphadenosis,
- acute leukemia (not always),
- autoimmune inflammations:
- rheumatoid arthritis,
- Felty's syndrome,
- systemic lupus erythematodes,
- hemolytic anemias:
- autoimmune hemolytic anemia,
- hereditery spherocytosis,
- hemoglobinopathies,
- glycogenoses, mucopolysaccharidoses and other thesaurismoses,
- amyloidosis,
- primary and secondary splenic tumours.
In congestive splenomegaly collagen is deposited in the walls of splenic sinusoids,
blood flow through the spleen is slowed down and the exposition of blood cells to
splenic macrophages increases - hypersplenism (enlarged spleen and loss of blood
cells of at least one cell line, which disappears following splenectomy)
6. The kidney
A normally-sized and located kidney is not palpable. A kidney may be palpated under
the following circumstances:
- dystopia of the kidney and a wandering kidney,
- renal polycystosis,
- hydronephrosis,
- tumour of a kidney or an adrenal gland.
7. The intestine
The intestine or its contents may be palpable under the following conditions:
- condensed stools (scybala),
- contracted intestine in the irritable bowel syndrome or in ulcerative colitis (usually
the colon descendens and sigma),
- Crohn's disease,
- inflammatory infiltrate in appendicitis, diverticulitis etc.,
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Seminar 7 Course 6 Module IIC
The reformed curriculum, Third Faculty of Medicine
Prof. Jiří Horák
- contraction of the intestinal loops at the beginning of an obstructive ileus,
- large tumours.
8. The urinary bladder
-
retention of the urine.
9. Female reproductive organs
- enlarged uterus (gravidity, myoma, tumours),
- extrauterine gravidity.
10. The lymph nodes
- inflammatory lymphadenomegaly (esp. in children),
- Whipple's disease,
- lymphoma,
- metastases to the lymph nodes (seminoma etc.)
11. The peritoneum
-
TBC peritonitis,
-
tumour infiltration of the omentum
12. Other causes
-
abscess,
-
tumours of unknown origin.
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