ABDOMINAL SWELLING, FOCAL

Ask the following questions:

1. Is it in the right upper quadrant? A mass in the right upper quadrant is most often an enlarged liver. However, the liver may be pushed down by a subphrenic abscess, and there may be an enlarged gallbladder due to cholecystitis or bile duct obstruction. There may be perinephric abscesses, tumors of the colon, renal tumors, adrenal tumors, hydrops of the gallbladder, fecal impaction, or an abdominal wall hematoma.
2. Is it in the epigastrium? A mass in the epigastrium also may be an enlarged liver, but other types of masses must be considered, including an omental hernia, pancreatic tumor, pancreatic cyst, gastric carcinoma, pyloric stenosis, aortic aneurysm, and retroperitoneal sarcoma.
3. Is it in the left upper quadrant? Left upper quadrant masses are often a splenomegaly, but abdominal wall hematomas occur in this area, as well as pancreatic tumors, pancreatic cysts, gastric tumors, colon tumors, kidney tumors or enlargement, and fecal impaction.
4. Is it in the right lower quadrant? A mass in the right lower quadrant is frequently a carcinoma of the colon, appendiceal abscess, psoas abscess, pyosalpinx, regional ileitis, intussusception, or an ovarian tumor.
5. Is it in the hypogastrium? A mass in the hypogastrium may be bladder, pregnant uterus, uterine fibroids, regional ileitis, urachal cyst, omental cyst, and rarely, endometrial carcinoma.
6. Is it in the left lower quadrant? A left lower quadrant mass is most often a palpable sigmoid colon, but pathologic conditions such as diverticulitis with abscess, carcinoma of the colon, and ovarian tumors may be present.
7. Is the mass tender? The presence of a tender mass in the right upper quadrant often means congestive heart failure, a tender liver from hepatitis, or a tender gallbladder from cholecystitis, subphrenic abscess, perinephric abscess, or an abdominal wall hematoma. A tender mass in the epigastrium may be a pancreatic cyst. A tender mass in the left upper quadrant may be an abdominal wall hematoma or a perinephric abscess. A tender mass in the right lower quadrant may be appendiceal abscess, psoas abscess, pyosalpinx, regional ileitis, or intussusception. A tender mass in the left lower quadrant may be a diverticulitis or pyosalpinx.
8. Is there blood in the urine or stool? The presence of blood in the urine, of course, would suggest a tumor of the kidney such as hypernephroma or Wilms' tumor. The presence of blood in the GI tract would suggest either a gastric carcinoma or colon carcinoma but may also be seen in intussusception, diverticulitis, and regional ileitis. Occasionally, it is seen in carcinoma of the ampulla of Vater.
9. Is there fever? The presence of fever would suggest that the mass is an abscess such as subphrenic abscess, perinephric abscess, diverticular abscess, appendiceal abscess, or pyosalpinx. Fever also suggests hepatitis, cholecystitis, or cholangitis.

DIAGNOSTIC WORKUP

Routine diagnostic tests include a CBC, sedimentation rate, urinalysis, chemistry panel with electrolytes, amylase and lipase, stool for occult blood, EKG, chest x-rays, and a flat plate of the abdomen. A carcinoembryonic antigen (CEA) test may diagnose colon cancer. Alpha 1-fetoprotein may diagnose carcinoma of the liver. If there are chills and fever, blood cultures ought to be done. Next in line are contrast radiographic studies such as upper GI series, barium enema, small bowel series, intravenous pyelogram, or cholecystogram.

At this point, before ordering more expensive tests, a surgeon or gastroenterologist should be consulted. An abdominal ultrasound will be helpful in differentiating cholecystitis and other cystic masses of the pancreas, kidneys, and reproductive organs.

Endoscopic procedures will help diagnose carcinoma of the stomach and colon and diverticulitis. ERCP is useful in diagnosing carcinoma of the pancreas and bile ducts.

Lymphangiography will help differentiate retroperitoneal tumors. CT scans of the abdomen and pelvis are useful in differentiating all types of masses. Gallium scans will help uncover subdiaphragmatic, perinephric, diverticular, and pelvic abscesses. Peritoneal taps will help differentiate ascites, pancreatitis, and peritoneal bleeding. Needle biopsy of the liver or any mass lesion under laparoscopic guidance may be diagnostic. A laparoscopy is useful in differentiating many types of masses also. Ultimately, exploratory laparotomy is still an excellent way of establishing a diagnosis.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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