Abdominal Masses

Prof.Dr. Serdar Yceyar

Department of Surgery
 ABDOMINAL MASSES
z The patient with an abdominal mass;
Rarely has an acute problem
Time to evaluation
An abdominal mass;
Unlike abdominal pain
Never functional
An organic disease
 Nonpathologic Masses
It is essential to establish before some investigative studies.
z Feces : fecal-filled colon
may be constipated
z Pregnancy :
z Bladder ( distented ) suprapubic mass
z Liver
z Aorta : Atherosclerotic
pulsatile
z Promontorium

SIZE OF THE MASS

The larger mass , the more advanced process
 PROBABILITY and POSSIBILITY
There are three informative factors
z Location of the mass
A mass at a certain site some anatomic
possibilities must be known
The most likely diseases that can be develop
in the suspected organs should be reviewed.
This knowledge can give the clinician an obvious
place to start .
 Age :
z In neonates ---- congenital malformation
or one of two neoplasms ( Wilms`s tm or neuroblastoma )
z In young adults------ secondary to an inflammatory process
z In middle-aged or older patients -----
Degenerative or neoplastic lesion ( more likely possible )
nflammatory lesions ( diverticulitis )
nflammatory complications ( degenerative and neoplastic lesions )
Sex
z In elderly women --- the tumors of ovary and uterus
z Colon cancers --- in both sexes
z Aneursym of abdominal aorta --- in men
 Incidence of disease
We have to think globally .
z What is common in some countries and in some
races ? .
In North America --- cholelithiasis ( gallbladder disease )
In Asia or Africa ---- Liver disease ( infective or neoplastic )
In elderly woman ---- right lower quadrant mass
( ovary or cecum )
In the left upper quadrant --- Left flexura of colon or spleen
( colon lesions are much more likely to cause the
symptoms )
 Incidence
z Cancer of the pancreas is common but a
detectable mass is uncommon
z A retroperitoneal sarcoma is rare --- but A
palpable mass is principle clinical feature
 Disturbance of function
A change in function :
It draws attention to the appropriate organ
There are to ways
1- Increased function :
z ( Least common )
Some functioning abdominal tumors secrete hormones.
The clinical manifestations are due to the effects of the hormones
on target tissue .
- Abnormal high serum hormone levels.
- But in these tumors , a palpable mass is rare .
( only some adrenal tumors can be detected )
The largest endocrine tumors are ovary tumors
 2- Impaired function :
( Much more common )
z A colonic mass will obstruct the bowel
z An intususseption obstruction
z Head of the pancreas jaundice
z Antrum of the stomach vomiting
Clinical manifestations of disease
History and physical examination
z A mass can results from a mechanical event
z Distended bladder - enlarged prostate
z Abdominal wall hematoma car accident
z Secondary to a degenerative process
( Abdominal aortic aneursym )
Inflammation
z Local manifestations:
Pain, tenderness, rebound and guarding
z Systemic manifestations
Fever , leukocytosis , and toxicity
z Can be the result of
traumatic
metabolic
infective processes.
z In acute infection symptoms are impressive
z Subacute or chronic inf.- few local , no systemic sign
z If the process is suppurative whitecell count and fever are high,
The fever is spiking and the patient is toxic the mass is an
abscess
A mass may be the results of an inflammatory process
, or inflammation can develope secondarily .
z Right lower quadrant appendiceal abscess
z Plastrone ( adjacent viscera are attracted to walloff the process )
z A similar process acute cholecystitis
Neoplastic mass is nontender ( not a rule )
z But in acute hemorhage into the tumor , a visceral pain may
occur
z Tumor may perforate ,and cause to an abscess and tenderness .
Chronic inflammation is more difficult to diagnose or to
identify from a neoplasm .
Mode of onset :
The rate of enlargement of a mass is important
in its cause .
z Suddenly
usually has a mechanical component
obstruction ( bladder , gallbladder , intususseption )
hemorhage ( rupture or into the tumor )
z takes a several days
inflammatory
z insidiously develops
secondary to degeneration
chronic inflammation
tumor
 Characteristics of the mass
z Mobility:
Located to the organ (according to the mobility of organ itself)
Has not extended to involve adjacent tissues
Lesions in fixed organ are immobile at the begining
In transvers colon or sigmoid mobile at the begining .
Mass changes in position with respiration
z Attached to the diphragm ,or
Associated with the diaphragmatic excursion ( liver , spleen or
kdney ).
 Pulsation :
Aortic aneursym
Adjacent to the main arteries
Highly vascular tumors
Tenderness
Inflammatory or has a significant inflammatory component.
Enduration
Hard or firm
Rubbery
Boggy
Changing in the shape
Surface
Nodularity or roughy
Smoothness
LOCATION OF THE MASS
The abdominal wall
Skin
Subcutaneous tissue
Fascia and muscle Rectus hematoma
Lipoma
Abdominal wall tumors
Hernia
Intra- and retroperitoneal masses :
It is difficult to differentiate a tumor arising within and posterior
to the peritoneal cavity .
Anatomic variability is important
Situs inversus
Partial malrotation of the gut
 RIGHT UPPER QUADRANT
z Liver
z Gallbladder
z Right kidney
z Hepatic flexura of the colon
z Stomach and duodenum
z Head of the pancreas
z Retroperitoneal nodes
z Right adrenal gland

Gallbladder
Chronic mucocele ( Hidrops vesicular )
 Liver
z The liver is the largest organ of the region and is frequently site of the Benign and malignant
masses
z And usually asymptomatic
z The mass may be in the right or left lobe of the lver .
z In the left lobe the mass may be in the epigastrium or even in the LUQ
z Asymptomatic space-occupying lesions
Primary or secondary tumors
Congenital or infective ( amebic or hydatid ) cysts
z US or CT
z Isotope scaning - cold region

Kidney
Intravenous urography
Retrograd urography
US
CT
Other sites
Hepatic flexure of the colon
z Palpable mass
z Symptom
Bleeding ( iron deficiency anemia , occult blood in stool , mass )
Obstruction ( Partial )
z Barium enema
z Colonoscopy
z CT
Stomach
Duodenum
Pancreas
z Barium meal
z Upper endoscopy
z US and CT
Other retroperitoneal tumors
z US , CT
z Percutaneous needle biopsy ( except Adrenal tumors )
z When still in doubt laparotomy or laparoscopy
THE EPIGASTRIUM
Liver
Body of the pancreas
Stomach
Colon ( Transverse )
Retroperitoneal tumors
z Upper GIT radiocontrast meal
z Endoscopy
z US , CT
LEFT UPPER QUADRANT
Asymptomatic
z Kidney
z Spleen ( the most likely organ to cause a palpable mass )
Tm. or splenomegaly
z Other structures
Left lobe of the liver
Splenic flexure of the colon
Adrenal gland
Other retroperitoneal tumors
z US , CT
z sotopic studies
RIGHT LOWER QUADRANT
Cecum
Ovary
Appendix
Small intestine
Mesentery
Omentum
Retroperitoneal tumors
 Cecum
Cancer ( anemia , mass , occult blood in the stool )
Tbc , actinomicozis , Crohns disease , lymphoma , Ameboma
Barium enema and colonoscopy is diagnostic
Ovary
Tms and cysts
Pelvic examination , US , CT
Appendix
Complications of appendicitis
Abscess , Plastrone
Small intestine
Crohns disease
( Mass , abdominal pain , weight loss , diarrhea )
MID ABDOMEN
Particular importance to aorta
z Prior to rupture asymptomatic
z Pulsatile mass
z Bruit
US , CT is sufficiently diagnostic
Aortography is invasive
LEFT LOWER QUADRANT
Descending or sigmoid colon
Ovary
Small intestine
Mesentery
Omentum
Retroperitoneal masses
z Diverticulitis is the commonest pathology
z Fecalom
z Sigmoid colon tms
 SUPRAPUBIC MASS
z Bladder
z Uterus
z Small intestine , colon , ovary , omentum
Generalized Abdominal swelling
z Bowel obstruction
z Ascites
z Big cysts of ovary