Abdominal Swellings
Abdominal swellings may be divided into generalised and localised swellings. Abdominal swellings are a common surgical problem. They are also frequently the subject of examination questions! Generalised swellings are classically described as the ‘five Fs’, namely fat, faeces, flatus, fluid or fetus. For the purpose of description of localised swellings, the abdomen has been divided into seven areas, i.e. right upper quadrant, left upper quadrant, epigastrium, umbilical, right lower abdomen, left lower abdomen and suprapubic area. Hepatomegaly, splenomegaly and renal masses, although referred to in this section, are dealt with under the relevant heading in the appropriate section of the book.
Right Upper Quadrant
Causes
Liver
See hepatomegaly, p. 229.
History
Liver
See hepatomegaly, p. 229.
Gall bladder
Known history of gallstones. History of flatulent dyspepsia. Jaundice. Dark urine. Pale stools. Pruritus. Recent weight loss may suggest carcinoma of the head of the pancreas or carcinoma of the gall bladder.
Right colon
Lassitude, weakness, lethargy suggesting anaemia from chronic blood loss. Central abdominal colicky pain, vomiting and constipation and change in bowel habit will suggest colonic carcinoma. There may be a history of gross constipation to suggest faecal loading. Known history of diverticular disease. History of attacks of crying, abdominal pain and blood and mucus in the stool (‘redcurrant jelly’ stool) will suggest intussusception in infants.
Right kidney
See kidney swellings, p. 299.
Examination
Gall bladder
A mucocele is either non-tender or only mildly tender. It is large and smooth and moves with respiration, projecting from under the ninth costal cartilage at the lateral border of rectus abdominis. Empyema presents with an acutely tender gall bladder, which is difficult to define due to pain and tenderness. The patient may be jaundiced due to Mirizzi syndrome (external pressure from a stone impacted in Hartmann’s pouch on the adjacent bile duct). Carcinoma of the gall bladder may present as a hard, irregular mass in the right hypochondrium, but normally presents as obstructive jaundice due to secondary deposits in the nodes at the porta hepatis causing external compression of the hepatic ducts. A smooth enlarged gall bladder in the presence of jaundice may be due to carcinoma of the head of the pancreas (Courvoisier’s law: ‘in the presence of obstructive jaundice, if the gall bladder is palpable, the cause is unlikely to be due to gallstones’).
Right colon
Faeces are usually soft and putty-like and can be indented but may also feel like a mass of rocks. Carcinoma is usually a firm to hard irregular mass, which may be mobile or fixed. A diverticular mass is usually tender and ill-defined, unless there is a large paracolic abscess. With caecal volvulus, there is a tympanitic mass which may be tender with impending infarction. With intussusception, there will be a smooth, mobile tender sausage-shaped mass in the right hypochondrium. The mass may move as the intussusception progresses.
Right kidney
See kidney swellings, p. 299.
General Investigations
■ FBC, ESR
Hb ↓ anaemia, e.g. carcinoma of the colon, haematuria with renal lesions. Hb ↑, e.g. hypernephroma (polycythaemia associated with hypernephroma). WCC ↑, e.g. empyema, diverticular mass. ESR ↑, malignancy.
■ U&Es
Vomiting and dehydration, e.g. gall bladder and bowel lesions. Ureteric obstruction with renal lesions leading to uraemia.
■ LFTs
Liver lesions. Secondary deposits in liver.
■ MSU
Renal lesions – red blood cells, pus cells, malignant cells. C&S.
■ AXR
Intestinal obstruction due to carcinoma of the large bowel. Gallstones (10% are radio-opaque). Caecal volvulus. Constipation. Calcification in renal lesions.
■ US
Liver lesions. Gallstones. Mucocele. Empyema. Bile duct dilatation.
Specific Investigations
History
Spleen
See splenomegaly, p. 425.
Stomach
Vomiting will suggest pyloric stenosis, acute dilatation of the stomach and carcinoma. Vomiting food ingested several days previously suggests pyloric stenosis. Lethargy, loss of appetite and weight loss are seen in carcinoma of the stomach.
Pancreas
There may be a history of acute pancreatitis, which would suggest the development of a pseudocyst. Weight loss, backache and jaundice will suggest carcinoma of the pancreas. Recent onset of diabetes may occur with carcinoma of the pancreas.
Kidney
See kidney swellings, p. 299.
Colon
Lower abdominal colicky pain and change in bowel habit may suggest carcinoma or diverticular disease. A long history of constipation may suggest faecal masses.
Examination
Stomach
Gastric distension may present with a vague fullness and a succussion splash. Carcinoma will present with a hard, craggy, immobile mass. Pancreatic tumours may be impalpable or present as a fixed mass, which does not move with respiration. Pancreatic pseudocysts are often large, smooth and may be tender.
Colon
See right upper quadrant, p. 11.
General Investigations
■ FBC, ESR
Hb ↓ carcinoma. Hb ↑ hypernephroma (polycythaemia is associated with hypernephroma). WCC ↑ diverticular disease, renal infections.
■ U&Es
Vomiting, dehydration (with gastric and colonic lesions). Renal lesions.
■ LFTs
Liver lesions. Secondary deposits in liver.
Specific Investigations
■ Blood glucose
May be raised in pancreatic carcinoma.
■ Barium enema
Carcinoma. Diverticular disease.
■ Colonoscopy
Carcinoma. Diverticular disease.
■ Gastroscopy
Carcinoma of the stomach. Pyloric stenosis.
■ CT
Carcinoma of the pancreas. Pancreatic pseudocyst. Liver secondaries. Splenomegaly. Paracolic abscess.
Epigastrium
Many of the swellings that occur here will have been described under swellings in other regions of the abdomen. Although a full list of epigastric swellings is given below, only those not referred to in other sections will be discussed in the history and examination sections.
