Teaching Plan 4

What’s the problems of these patients??

Abdominal masses

overview • Not easy to be detected by patient

himself • Usually detected by routine physical examination • Most of them develop slowly • cryptic

overview Abdominal mass

abscess

Problem with a blood vessel

Enlarged Organ (spleen, kidney, liver etc.)

Accumulation tumor of feces

Symptoms and signs

Symptoms

Abdominal aortic aneurysm • Pulsating mass around navel

aneurysm

postoperation

Bladder distention • Firm mass in the

center of lower abdomen above pelvic bones • Some can extend as far up as navel

cholecystitis • Tender mass felt below the liver in RUQ

COLON CANCER • Mass anywhere in abdomen

Crohn’s disease or bowel obstruction • Multiple tender, sausage-shaped masses

diverticulitis • Mass located in LLQ

Gallbladder tumor • Moderately tender, irregularly shaped mass in RUQ

hydronephrosis • Smooth ,

spongy-feeling mass • In one or both sides or toward the back

Kidney cancer • Sometimes a mass in abdomen

Liver cancer • A firm, lumpy mass in RUQ

Liver enlargement (hepatomegaly) • Firm, irregular mass below right rib cage (right costal margin) • Or on the left side in stomach area (epigastric)

neuroblastoma • Malignant tumor • In lower abdomen • Occurs in children and in fants

Ovarian cyst • Smooth, rounded, rubbery mass above pelvis in lower abdomen

Pancreatic abscess • Mass in epigastric area of upper abdomen

Pancreatic pseudocyst • Lumpy mass in epigastric area of upper abdomen

Renal cell carcinoma • Smooth, firm, nontender mass near (usually one side)

Spleen enlargement (splenomegaly) • Edge of enlarged spleen felt in LUQ

Stomach cancer • Mass in epigastric area of left-upper abdomen

Uterine leiomyoma ( 平滑肌 瘤) • Round, lumpy mass above pelvis in the lower abdomen

Volvulus • A mass anywhere in abdomen

Ureteropelvic junction obstruction • A mass in lower abdomen

signs • 4 quadrants: RUQ, RLQ, LLQ, LUQ • Periunbilical • Epigastric: area in the center of abdomen below the ribcage

diagnosis history

location

Time pattern

other

location • Upper abdomen?

RUQ? LUQ?

Upper-middle area? • Lower abdomen? RLQ? LLQ? • Around navel? • In the groin? (inguinal)

Time pattern • How long ago was it noticed? • Come and go? • How often have you seen it?

other • Changes in size, position, extent of discomfort, or in any other way?

Differential diagnosis

Differentiation • Huge ovarian cyst √ a large area of dullness at midabdomen √ tympany at laterals (bowels could be pushed to the bilateral flanks) √ The dullness of ovarian cyst could not shift.

Differentiation • Ruler pressing test √ to differentiate huge ovarian cyst from real ascites √ take the supine position, a hard ruler on the patient’s abdominal wall horizontally, presses the ruler downward with two hands

Differentiation • If huge ovarian cyst exists,

the pulsation of abdominal aorta will conduct to the ruler via the cyst, leading to rhythmic pulsation of the hard ruler.

• If free fluid, not cyst, exists

in the abdominal cavity, the pulsation of abdominal aorta could not conduct, so the hard ruler has no such rhythmic pulsation.

Differentiation • pregnancy √ breast engorged √ fetal movement and parts may be felt , fetal heart should be audible √ cervix softened

Differentiation • cecum

√ cecum felt: indistinct soft mass, slightly tender, fluctuant firmer mass felt: √ tuberculous granuloma √pericecal or appendiceal abscess √crohn disease √carcinoma

Differentiation • feces √ irregular plastic masses of feces may be palpated in sigmoid √ it can move or disappear in 1 or 2 days

Differentiation • Enlarge d

Enlarged kidney

kidney

congenital

Inflammatory/ Mechanical/ neoplastic immune trauma

Differentiation • Enlarged kidney--

congenital √ polycystic kidney disease √ horseshoe kidney √compensatory ypertrophy opposite absent kidney √idiopathic. Cyst( 先天性的

Differentiation • Enlarged kidney--

Inflammatory/immune √ amyloidosis ( 淀粉样变性）

Differentiation • Enlarged kidney--

Mechanical/trauma √ hydronephrosis √ hematoma

Differentiation • Enlarged kidney-- neoplastic √ renal cell carcinoma √ renal sarcoma ( 肉瘤 ) √transitional cell carcinoma of renal pelvis and ureter

Differentiation • Enlarged kidney √ lacks the sharp edge the spleen and liver may present √ lobulation of kidney may be mistaken for spenic notch √enlarged kidney may be more often irregular than spleen √renal mass do not move with deep inspiratory effort, unlike spleen and liver, because of retroperitoneum

Other abdominal mass • Volvulus • Intussusception • Abscess • Enlarged tender gallbladder • Distended urinary bladder • Abdominal, inguinal, and other hernia

Enlarged tender gallbladder • Progressive enlargement of the gallbladder-obstruction of common bile duct • Nontender gallbladder—stones, acalculous cholecystitis, gallbladder hydrops • Contracted gallbladder—chronic cystic duct obstruction • Dilatation of gallbladder—carcinoma of the head of pancreas but not with common duct stone • Hard, irregular mass, tender—carcinoma of gallbladder

Distended urinary bladder • In midline, may reach the umbilicus • Dull to percussion • Fluctuant • Painless • Disappears wit catheterization

Abdominal, inguinal, and other hernia • Abdominal heania: Incisional henia • Operative scar • Defect in abdominal wall • Valsalva maneuver or raise head while supine: herniation occurs adjacent to the scar

Luxembourg