ABDOMINAL MASS

CAUSES OF AN INTRA-ABDOMINAL MASS Intra-abdominal mass can be subdivided into: 1. Inflammatory 2. Cystic (primary or secondary to inflammation) 3. Neoplastic (benign, malignant or vascular) Diseases of the appendix, the gallbladder, the pancreas, and diverticular disease of the colon can all, after the acute phase of the disease, give rise to the development of an intra-abdominal mass. Examples: o Cystic lesions of pancreas and the liver (including hydatid disease of the liver) and the mesentery can present with a mass on physical examination. o Tumours of the pancreas and colon are the most common causes of tumours giving rise to a mass as the primary presenting symptom. o An aneurysm of the abdominal aorta is the only clinically relevant example of a vascular cause of an intra-abdominal mass. DIAGNOSIS OF AN INTRA-ABDOMINAL MASS Clinical history The patient is unlikely to tell the general practitioner that he has an abdominal mass although some patients do worry about a prominent xiphisternum or have discovered a hernia. Almost always the accompanying symptoms are non-specific: a dull, vague intra-abdominal pain or a sensation of fullness. Additional symptoms such as fever, weight loss, loss of appetite, dyspepsia, or changes in bowel habit may supply further information. Because of the potential causes of an intra-abdominal mass, a full history including detailed information on eating, drinking, appetite, defaecation, the menstrual cycle, and previous infectious diseases, is a crucial to inform further diagnostic steps. Physical examination

On physical examination, the general impression (weight loss, anaemia, fever) is the first step in deciding whether there is an inflammatory process, a benign cyst or tumour, or a malignant disease as the cause of the abdominal symptoms.

Inspection does not usually have diagnostic value in the case of a mass. Abdominal wall mass is more prominent on tensing of abdominal wall muscles ask patient to raise head or feet off bed

Intra-abdominal mass is less prominent on tensing of abdominal wall muscles

At auscultation of the abdomen, the signs of obstruction can signal the presence of a tumour compressing the bowel, leading initially to small bowel obstruction, or growing into the lumen.

Percussion is dull over tumours, cysts, and inflammatory masses. An inflammatory mass is difficult to exactly delineate on palpation, whereas tumoyrs of the gastrointestinal tract, pancreas, or liver are more circumscribed. If they can be felt on palpation, this is usually a sign of advanced disease, leaving little room for favourable prognosis.

Cystic lesions are usually not fixed and move with the adjacent organ on respiration.

An aneurysm of the abdominal aorta exhibits expansile pulsations. A tumour overlying the aorta can mimic these pulsations, but without being expansile. An aortic aneurysm is usually asymptomatic and if found, this must not be held responsible for the patients symptoms too easily.

Specific diagnosis a) Inflammatory mass If an inflammatory is suspected, this is usually originates from the gallbladder, the appendix, the sigmoid colon, or the pancreas.

The mass develops in a late (after 72 h or more) phase of the acute inflammation, when it has been sealed off by adjacent organs and greater omentum. This forms an infiltrate with dull percussion and a palpable mass which is difficult to exactly delineate.

If there is doubt about the diagnosis, additional investigations such as ultrasonography (to diagnose gallstones), CT scanning (to differentiate appendicitis from a caecal tumour or diverticular disease from a tumour of the sigmoid colon) is mandatory, not because of the immediate clinical consequences but to make further plans and to inform the patient.

The diagnosis of acute cholecystitis is a clinical one; the right upper abdominal mass may also be caused by a hydrops or empyema of the gallbladder. Ultrasonography is only helpful to demonstrate the stones, not to establish the diagnosis of an inflamed gallbladder.

b) Neoplastic mass If physical examination has revealed an intra-abdominal mass, and inflammatory cause is considered unlikely, it may be a neoplasm originating from colon, pancreas, liver, stomach, or small bowel. The first step is often endoscopy with histology. Once the diagnosis of a malignant tumour is established, CT scanning is the investigation of choice to decide whether surgery is indicated to prevent bleeding and obstruction. If the palpable mass is localized in the right upper quadrant and moves on respiration, it is growing from the liver. In that case, CT scanning can differentiate between a cyst, a tumour (primary or secondary), or hydatid disease (with the typical intracystic septa). If the palpable mass is localized in the middle upper abdomen and a pancreatic tumour is suspected, by far the highest diagnostic yield can be expected from a contrast-enhanced CT scan (taken with small slices in the

area of the pancreas). Thus, signs of irresectability (such as invasion of adjacent vital structures) or incurability (e.g metastatic disease in lymph nodes or liver) can be adequately demonstrated. c) Cystic lesions Cystic lesions are rare cause of a palpable mass, usually originating from the pancreas, the liver, and the kidney. In general have, only large cysts can be palpated on physical examination.

Pancreatitis cysts are usually pseudocysts which have developed in the

course of acute or chronic pancreatitis. Often they are assymptomatic and apparently harmless.

Hepatic cysts may be unilocular and only require treatment when they
become symptomatic, usually as a result of bleeding. A unilocular cyst can be caused by hydatid disease or by amoebiasis. Serology, ultrasound, and CT scanning help to differentiate these infections from the harmless unilocular cyst. Multiple cysts can develop in the course of adult polycystic liver disease. Like Swiss cheese there are multiple cysts with only remnants of liver in between them. Pancreatic and renal cysts also occur in this type of polycystic disease.

Renal cysts are frequently observed as an incidental finding on CT scanning.

Single cysts are assymptomatic, cannot be palpated on physical examination, and have no implication for treatment. If the kidney is affected by polycystic disease, renal failure is often the first sign of disease. Pain can occur because of bleeding into one of the cysts. A mass with a tendency to move downwards on deep respiration can be palpated.

OTHER CAUSES OF ABDOMINAL MASS A palpable spleen usually indicates severe disease such as myelofibrotic syndrome, or severe portal hypertension with secondary enlargement of the spleen. A

moderately enlarged spleen, as seen in sepsis, severe infectious disease and splenic vein thrombosis, is not normally palpable on physical examination. An enlarged uterus usually indicates pregnancy. Only very large myomas can be diagnosed on physical examination. In the Western world, malignant tumours of the ovaries, endometrium, or cervix are usually diagnosed long before they give rise to the formation of an intra-abdominal mass, but late presentations often occur in the developing world. An enlarged bladder means that the patient desperately needs catheterization. A palpable aorta can erroneously lead to referral because an aortic aneurysm is suspected. Only if the pulsations of the aorta are expansile is the suspicion justified. The size of aneurysm can easily be assessed by ultrasonography and if the diameter exceeds 6 cm, there is an increased risk of rupture and a good argument for surgical treatment if the patient represents an acceptable anaesthetic risk.

Source: Abdominal Mass, Oxford Textbook of Primary Medical Care, Volume 2

Table 36.1 CAUSES OF ABDOMINAL AND RECTAL MASSES

Involved Organ Liver Etiologies of Masses Hemangioma, adenoma, focal nodular hyperplasia, focalfatty infiltration, hepatocellular carcinoma, metastases Adenocarcinoma, lymphoma, neuroendocrine tumors, pseudocysts, mucinous cystadenoma, cystadenocarcinoma Renal cell carcinoma, transititional cell carcinoma, lymphoma, renal oncocytoma, cysts Adenocarcinoma, adenoma, lymphoma, hyperplastic polyp, hamartoma, leimyoma, lelomyosarcoma, leioblastoma, Gastrointestinal tract Kaposis sarcoma, carcinoid, colitis, cystic profunda, lipoma, neuroma, schwannoma, inflammatory mass (Crohns, appendicitis), abscess

Pancreas Kidney

Miscellaneous

Mesenteric cyst, cystic teratoma, cystic mesothelioma, hematoma, abscess, abdominal aortic aneurysm

Source: Approach to the Patient with an Abdominal or Rectal Mass, Kelley's Essentials of Internal Medicine, 2e.
Masses that involving the luminal gastrointestinal tract are prevalent. Adenocarcinoma accounts for 95% of gastric cancers, with lymphoma representing the second most common cell type. Small intestinal masses more commonly are benign and include adenomas, hamartoma, fibromas, and angiomas. Adenocarcinoma, leiomyosarcoma, and lymphoma are malignancies that arise from the small intestine. The most common colorectal masses are benign polyps, including nonadenomatous (hyperplastic, hamartoma) and adenomatous growths. Adenocarcinomas constitute the majority of colorectal cancers, although lymphoma and Kaposis sarcoma also occur. Benign colonic masses may be due to perforation of an inflamed appendix or inflammation from Crohns disease. The appearance of colorectal cancer can be mimicked by colitis cystic profunda, a benign disease characterized by submucosal mucus-filled cysts. Carcinoids arise most commonly in the appendix, followed by the ileum, rectum, and stomach. Tumors that originate from smooth muscle (leiomyoma, leiomyosarcoma) or fat (lipoma, liposarcoma) ma develop throughout the digestive tract. Less common cell types include neurofibromas, schwannomas, and leioblastomas. DIAGNOSTIC TESTING Laboratory tests play minor roles in the evaluation of an unexplained abdominal or rectal mass. A complete blood count can test for anemia due to blood loss or chronic disease or for leukocytosis with inflammation. Liver chemistries may be abnormal with some hepatic masses. Serum tumor markers may provide adjunctive information in the diagnostic workup. CA 19-9 and CA 242 are reasonably sensitive for detecting pancreatic adenocarcinoma but are not specific. Carcinoembryogenic antigen is elevated with colon cancer as well as in benign liver and pancreatic diseases. Alpha-fetoprotein is secreted by larger hepatocellular carcinomas. It

ascites is present, cytologic examination may reveal malignant cells. High levels of ascetic triglycerides indicate chylous ascites, possibly due to lymphoma. Endoscopic testing is of great usefulness in the diagnosis of luminal masses both because of the ability to view suspicious lesions directly and because of the capability to obtain biopsies. A standard gastroscope evaluates to the duodenal sweep. Enteroscopy can be used to evaluate more distal small intestinal masses. Sigmoidoscopy reveals the distal 60 cm of the colon, and colonoscopy provides a complete evaluation. Endoscopic retrograde cholangiopancreatography can show filling defects within pancreas or biliary tree and can obtain diagnostic brushings in about 50% of pancreaticobiliary neoplasms. Endoscopic ultrasound provides additional detail regarding tumors of luminal gut and of pancreas and bile ducts and can determine whether local disease extension precludes surgical resection.

Cross-sectional imaging techniques frequently are indicated to evaluate the source of an abdominal mass. Ultrasound is effective for imaging of the biliary tree and liver. Computed tomography provides a more detailed and comprehensive evaluation of visceral organs. In equivocal cases, magnetic resonance imaging further characterizes hepatic mass lesions, such as focal nodular hyperplasia and fatty infiltration. A vaiant of this test magnetic resonance cholangiopancreatography, was developed to assess for abnormalities within the bile and pancreatic ducts. Finally, in many instances, it is necessary to obtain tissue to distinguish accurately between a malignant and noncancerous cause of the mass.

Source: Chapter 93 Inspection, Auscultation, Palpation, and Percussion of the Abdomen, Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition.
Abdominal masses arise from the surrounding structures, thus the importance of topographic relationships. The presence or absence of tenderness of a mass gives important information as to its etiology. An appendiceal abscess will be tender as it inflames the parietal peritoneum, whereas carcinoma of the cecum will be nontender because there is no inflammation involved. Tympany over a mass implies it is gas filled. In the abdomen, this usually signifies the mass is dilated

bowel, as only rarely will there be enough gas in any other mass to produce tympany.

Inspection
This should be performed from several angles. It is important to differentiate abdominal wall from intra-abdominal masses. A mass of the abdominal wall will become more prominent with tensing of the abdominal wall musculature, whereas an intra-abdominal mass will become less prominent or disappear. Useful maneuvers are to have the patient hold his head unsupported off the examining table, to hold his nose and blow, or to raise his feet off the table. Abdominal wall masses are most commonly hernias (either umbilical, epigastric, incisional, or spigelian), neoplasms (benign and malignant), infections, and hematomas. Once a mass is determined to be intra-abdominal, its location should be described in relation to the abdominal quadrants. The relationship of intra-abdominal organs to these quadrants should be considered in attempting to determine the cause of the mass. The mass should be examined for movement with respiration or for pulsation with each heartbeat. Also, the mass should be observed for peristalsis, as it may well represent dilated bowel.

Masses noted on inspection of the abdomen may be related to organs in that area :
A mass in the right upper quadrant Hepatomegaly from hepatitis or hepatic tumor, a distended gallbladder from cholecystitis or pancreatic cancer, or a carcinoma in the head of the pancreas. An epigastric mass acute gastric distention. pancreatic pseudocyst, pancreatic cancer, or aneurysm of the abdominal aorta (which will be pulsatile). Masses in the left subcostal region Generally due to splenomegaly, although carcinoma of the spenic flexure of the colon is also a possibility. Masses in the lumbar region are generally of renal origin. Renal cysts, polycystic kidneys, and renal malignancies may all be visible in asthenic patients.

Masses in the lower quadrants may

In the right lower quadrant appendiceal

result from inflammatory or neoplastic disorders of the intestine.

abscess and cecal carcinoma are most likely, while in the left lower quadrant diverticular abscess or carcinoma of the sigmoid colon is most likely.

Hypogastric masses are the result of pelvic pathology

Acute urinary retention is the most common cause of such a mass in males. In females, uterine or ovarian neoplasms may cause visible midline abdominal masses.

Palpation When abdominal masses are palpated, the first consideration is whether the mass is intra-abdominal or within the abdominal wall. This can be determined by having the patient raise his or her head or feet from the examining table. This will tense the abdominal muscles, thus shielding an intra-abdominal mass while making an abdominal wall mass more prominent. If the mass is intra-abdominal, important points are its size, location, tenderness, and mobility. Palpation and Percussion Abdominal masses are related to the underlying organs. Right upper quadrant masses include hepatomegaly, hydrops of the gallbladder, and carcinoma of the head of the pancreas. Epigastric masses are pancreatic (pseudocyst or carcinoma), gastric malignancies, and colon malignancies. Masses in the left upper quadrant are usually due to either splenomegaly or carcinoma of the stomach or colon. In the flanks, masses usually arise from the kidney (cyst or tumor), although occasionally from other retroperitoneal structures (lymphoma, sarcoma). Masses in the lower quadrants usually arise from the bowel. On the right side, common masses include appendiceal abscess and cecal carcinoma; on the left, diverticular abscess and sigmoid carcinoma. Central abdominal masses are often aortic aneurysms, and the pulsatile nature of the mass is diagnostic. Thus, in evaluating an abdominal mass, one must consider its location, mobility, and the presence or absence of tenderness in order to define its etiology.