Differential diagnosis of abdominal masses, and Is an abdominal mass always cancer

An abdominal mass is an abnormal lump or swelling in the abdomen, which can arise from various organs, including the intestines, liver, kidneys, spleen, or reproductive organs. The cause of an abdominal mass can range from benign conditions to serious diseases, including cancer.

Causes of Abdominal Masses

Gastrointestinal Causes

• Hernia (inguinal, umbilical, incisional).
• Tumors (benign or malignant, e.g., colorectal cancer).
• Diverticular disease (diverticulitis with an abscess).
• Inflammatory bowel disease (Crohn’s disease with thickened bowel loops).

Hepatic (Liver) Causes

• Hepatomegaly (enlarged liver from fatty liver disease, hepatitis, or cirrhosis).
• Liver tumors (hepatocellular carcinoma, metastases).
• Liver cysts or abscesses.

Renal (Kidney) Causes

• Polycystic kidney disease.
• Renal tumors (renal cell carcinoma, Wilms’ tumor in children).
• Hydronephrosis (enlarged kidney due to obstruction).

Splenic Causes

• Splenomegaly (enlarged spleen due to infections, blood disorders).
• Splenic tumors or cysts.

Gynecological Causes

• Ovarian cysts or tumors.
• Uterine fibroids.
• Pregnancy-related masses (ectopic pregnancy, molar pregnancy).

Pancreatic Causes

• Pancreatic cysts or tumors.
• Chronic pancreatitis with pseudocyst formation.

Lymphatic Causes

Lymphadenopathy (enlarged lymph nodes due to lymphoma, tuberculosis).

Symptoms Associated with Abdominal Masses

• Pain or tenderness.
• Swelling or bloating.
• Nausea and vomiting.
• Changes in bowel habits (constipation, diarrhea).
• Unexplained weight loss.
• Jaundice (yellowing of skin and eyes, if liver involvement).
• Fever (if infection is present).

Diagnosis

Doctors use a combination of: Physical Examination (palpation to locate the mass).

Imaging Studies:

• Ultrasound.
• CT scan or MRI.
• Blood Tests (tumor markers, liver/kidney function tests).
• Biopsy (if cancer is suspected).

Treatment

Treatment depends on the cause and may include:

• Surgical removal (e.g., hernia repair, tumor excision).
• Medications (antibiotics for infections, chemotherapy for cancers).
• Lifestyle changes (dietary modifications for liver or gastrointestinal conditions).

Differential diagnosis of abdominal masses

Abdominal Examination

1. History taking:

In patients presenting with mass abdomen, generally following clinical features should be assessed carefully:

1. Pain: Site, nature, aggravating or relieving factors, duration of pain, referred pain.
2. Vomiting: Type, content, hematemesis, relation to food, frequency.
3. Jaundice: It is an important factor in relation to liver, gallbladder, or pancreatic masses.
4. Bowel habits: Constipation, diarrhea, bloody diarrhea, furious diarrhea, tenesmus.
5. decreased appetite and weight.

2. General examination

3. Local examination:

Position: Spine position

Exposure:

• Nipple to knee OR complete exposure of abdomen from xiphoid process to pubic or groin region.
• If it is embarrassing, cover the lower abdomen with the sheet.

Abdominal inspection

1. Abdominal shape & contour: (Normal – Scaphoid – Distended – Localized bulge).

A. Normal: Flat from xiphoid to pubis, and umbilicus is at the center of the abdomen.

B. scaphoid abdomen: dehydration, cancer stomach, T.B. peritonitis).

C. distended abdomen:

• Localized (asymmetrical): huge organomegaly, tumors, operation, hernia.
• Generalized (symmetrical): 6F’s Fetus: pregnancy, flatus: gaseous distention, faces: constipation, fat: obesity, Fluid: ascites, fibroid.

2. Flanks: (Full Flanks e.g. in ascites or empty flanks).

3. Epigastric pulsations: ask patient to hold his breath.

4. Subcostal angle:

• Normal: right angle (70-110 degrees).
• wide angle (abnormal): Organomegaly (liver or spleen), ascites, COPD e.g. emphysema.
• Narrow angle (abnormal): Flat chest, visceroptosis, Pigeon chest.

5. Divercation of the recti: Ask patient to sit up in bed unsupported (raising up test).

• due to chronic increase in intra-abdominal pressure leading to weak abdominal wall.
• It is important to differentiate the abdominal wall from intra-abdominal masses:

1. Abdominal wall mass: more prominent with tensing of abdominal wall musculature.
2. Intra-abdominal mass will become less prominent or disappear.

6. Respiratory movements:

• Normal: Abdominothoracic in males & thoracoabdominal in females.
• Absent: In peritonitis.
• Paradoxical: In unilateral diaphragmatic paralysis.

7. Hernial arifices:

• Expansile impulse on cough dt weak abdominal wall and increase IAP.
• Sites: Inguinal, umbilical, femoral, epigastric, incisional.

8. Umbilicus:

Site: normally midway bet. Xiphisternum and symphysis pubis.

• Shifted upwards in pregnancy, ovarian mass, tumor in pelvis.
• Shifted downwards in ascites, hepatosplenomegaly, tumor in upper abdomen.

Shape: normally inverted.

Everted in ascites and umbilical hernia.

umbilical hernia: by Impulses on cough test.

Pigmentation around umbilicus:

• Cullen sign: internal Hemorrhage leading to bluish discoloration of umbilicus due to ruptured spleen, acute hemorrhagic pancreatitis, disturbed ectopic pregnancy, Malignant tumor with internal bleeding.
• Lymphoma: Brownish color.

Abnormal discharge from umbilicus:

• Umbilical fistula: Fecal, urinary, biliary.
• Umbilical sinuses: abscess.

Dilated veins around umbilicus: (Caput medusa).

Nodules around umbilicus: Sister marry nodules: Indicate intra abdominal malignancy due to metastasis.

9. Skin: Skin pigmentation: Cullen sign (periumbilical); grey turner sign (flanks) bluish discoloration denoting intra-abdominal hemorrhage.

Scars: Types of scars: splenectomy (meddle line), nephrectomy, cholecystectomy (right), hysterectomy (suprapubic), appendicectomy (right iliac). Impulses on cough or not (To exclude incisional hernia).

Striae: Due to stretching of abdomen.

• Striae alba (in obesity pregnancy, ascites).
• Striae rubra (in Cushing, steroid uses, recent operation).
• Linea nigra (pregnancy line due to ⇑ melanin stimulating hormone from placenta).

Collateral (Dilated superficial veins): (dilated, elongated, tortious & congested).

Hair distribution: feminine hear distribution in liver disease.

scratch marks: in obstractive jaundice.

petechiae & Purpura (red spot): due to platelets’ disfunction.

Ecchymosis & hematoma: due to coagulation disfunction.

10. Supra-pubic region: distended or not.

Distended in distended bladder or ovarian cyst.

11. Intestinal movements: Visible peristalsis denoting intestinal obstruction.

Abdominal palpation:

1. Superficial Palpation: To gain the patient’s confidence, and to detect local temperature, tenderness, parietal mass, or hypersthesia.
2. Deep Palpation to feel the following:

• Abdominal organs: Liver, spleen, kidneys.
• abdominal aorta.
• Any masses.

If the patient is obese or rigid, use 2 hands to palpate; place one on the top of other hand and feel with the lower hand.

If masses are felt, note the following:

• Inspection of the mass (6S): Site, size, shape, surface, skin overlying, special character.
• Palpation of the mass: Site, extent, surface, tenderness, consistency, movement with respiration, mobility, borders, plane of the swelling (by leg-raising test), and presence of other masses.
• Often, the mass needs to be examined for change of position: in sitting, in standing, in side position, after a brisk walk, in knee-elbow position for retro-peritoneal mass and for puddle sign (but difficult to keep patient in this position).

Percussion:

Percussion over the mass is important to predict the anatomical location of the mass.

1. If the mass has a dull note, then it is in the anterior abdominal wall, or in front of the bowel intra-abdominally like liver, spleen, gall bladder (GB).
2. If the mass is with an impaired resonant note, then the mass is arising from the bowel like stomach, colon, or small bowel.
3. If the mass is resonant on percussion, then it is probably in the retro-peritoneal region.
4. Other than this, liver dullness, free fluid in the abdomen should be elicited during percussion.

other:

• Per-rectal (PR) examination: It is done to look for any secondaries in a recto-vesical pouch, primary tumor or relation of lower abdomen masses (pelvic masses).
• Per-vaginal (PV) examination: It is done to assess pelvic masses.

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