Abdominal Masses. Department of Surgery

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Evan Wilkerson
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1 Abdominal Masses Prof.Dr.. Serdar Yüceyar Department of Surgery

2 ABDOMINAL MASSES The patient with an abdominal mass; Rarely has an acute problem Time to evaluation An abdominal mass; Unlike abdominal pain Never functional An organic disease

3 Nonpathologic Masses It is essential to establish before some investigative studies. Feces : fecal-filled filled colon may be constipated Pregnancy : Bladder ( distented ) suprapubic mass Liver Aorta : Atherosclerotic pulsatile Promontorium SIZE OF THE MASS The larger mass, the more advanced process

4 PROBABILITY and POSSIBILITY There are three informative factors Location of the mass A mass at a certain site some anatomic possibilities must be known The most likely diseases that can be develop in the suspected organs should be reviewed. This knowledge can give the clinician an obvious place to start.

5 Age : In neonates ---- congenital malformation or one of two neoplasms ( Wilms`s tm or neuroblastoma ) In young adults secondary to an inflammatory process In middle-aged or older patients Degenerative or neoplastic lesion ( more likely possible ) İnflammatory lesions ( diverticulitis ) İnflammatory complications ( degenerative and neoplastic lesions ) Sex In elderly women --- the tumors of ovary and uterus Colon cancers --- in both sexes Aneursym of abdominal aorta --- in men

6 Incidence of disease We have to think globally. What is common in some countries and in some races?. In North America --- cholelithiasis ( gallbladder disease ) In Asia or Africa ---- Liver disease ( infective or neoplastic ) In elderly woman ---- right lower quadrant mass ( ovary or cecum ) In the left upper quadrant --- Left flexura of colon or spleen ( colon lesions are much more likely to cause the symptoms )

7 Incidence Cancer of the pancreas is common but a detectable mass is uncommon A retroperitoneal sarcoma is rare --- but A palpable mass is principle clinical feature

8 Disturbance of function A change in function : It draws attention to the appropriate organ There are to ways 1- Increased function : ( Least common ) Some functioning abdominal tumors secrete hormones. The clinical manifestations are due to the effects of the on target tissue. - Abnormal high serum hormone levels. - But in these tumors, a palpable mass is rare. ( only some adrenal tumors can be detected ) The largest endocrine tumors are ovary tumors hormones

9 2- Impaired function : ( Much more common ) A colonic mass will obstruct the bowel An intususseption obstruction Head of the pancreas jaundice Antrum of the stomach vomiting

10 Clinical manifestations of disease History and physical examination A mass can results from a mechanical event Distended bladder - enlarged prostate Abdominal wall hematoma car accident Secondary to a degenerative process ( Abdominal aortic aneursym )

11 Inflammation Local manifestations: Pain, tenderness, rebound and guarding Systemic manifestations Fever, leukocytosis, and toxicity Can be the result of traumatic metabolic infective processes. In acute infection symptoms are impressive Subacute or chronic inf.- few local, no systemic sign If the process is suppurative whitecell count and fever are high, The fever is spiking and the patient is toxic the mass is an abscess

12 A mass may be the results of an inflammatory process, or inflammation can develope secondarily. Right lower quadrant appendiceal abscess Plastrone ( adjacent viscera are attracted to walloff the process ) A similar process acute cholecystitis Neoplastic mass is nontender ( not a rule ) But in acute hemorhage into the tumor, a visceral pain may occur Tumor may perforate,and cause to an abscess and tenderness. Chronic inflammation is more difficult to diagnose or to identify from a neoplasm.

13 Mode of onset : The rate of enlargement of a mass is important in its cause. Suddenly usually has a mechanical component obstruction ( bladder, gallbladder, intususseption ) hemorhage ( rupture or into the tumor ) takes a several days inflammatory insidiously develops secondary to degeneration chronic inflammation tumor

14 Characteristics of the mass Mobility: Located to the organ (according( to the mobility of organ itself) Has not extended to involve adjacent tissues Lesions in fixed organ are immobile at the begining In transvers colon or sigmoid mobile at the begining. Mass changes in position with respiration Attached to the diphragm,oror Associated with the diaphragmatic excursion ( liver, spleen or kıdney ).

15 Pulsation : Aortic aneursym Adjacent to the main arteries Highly vascular tumors Tenderness Inflammatory or has a significant inflammatory component. Enduration Hard or firm Rubbery Boggy Changing in the shape Surface Nodularity or roughy Smoothness

16 LOCATION OF THE MASS The abdominal wall Skin Subcutaneous tissue Fascia and muscle Rectus hematoma Lipoma Abdominal wall tumors Hernia Intra- and retroperitoneal masses : It is difficult to differentiate a tumor arising within and posterior to the peritoneal cavity. Anatomic variability is important Situs inversus Partial malrotation of the gut

17 RIGHT UPPER QUADRANT Liver Gallbladder Right kidney Hepatic flexura of the colon Stomach and duodenum Head of the pancreas Retroperitoneal nodes Right adrenal gland Gallbladder Chronic mucocele ( Hidrops vesicular )

18 Liver The liver is the largest organ of the region and is frequently site of the Benign and malignant masses And usually asymptomatic The mass may be in the right or left lobe of the lıver. In the left lobe the mass may be in the epigastrium or even in the LUQ Asymptomatic space-occupying lesions Primary or secondary tumors Congenital or infective ( amebic or hydatid ) cysts US or CT Isotope scaning - cold region Kidney Intravenous urography Retrograd urography US CT

19 Other sites Hepatic flexure of the colon Palpable mass Symptom Bleeding ( iron deficiency anemia, occult blood in stool, mass ) Obstruction ( Partial ) Barium enema Colonoscopy CT Stomach Duodenum Pancreas Barium meal Upper endoscopy US and CT Other retroperitoneal tumors US, CT Percutaneous needle biopsy ( except Adrenal tumors ) When still in doubt laparotomy or laparoscopy

20 THE EPIGASTRIUM Liver Body of the pancreas Stomach Colon ( Transverse ) Retroperitoneal tumors Upper GIT radiocontrast meal Endoscopy US, CT

21 LEFT UPPER QUADRANT Asymptomatic Kidney Spleen ( the most likely organ to cause a palpable mass ) Tm. or splenomegaly Other structures Left lobe of the liver Splenic flexure of the colon Adrenal gland Other retroperitoneal tumors US, CT İsotopic studies

22 RIGHT LOWER QUADRANT Cecum Ovary Appendix Small intestine Mesentery Omentum Retroperitoneal tumors

23 Cecum Cancer ( anemia, mass, occult blood in the stool ) Tbc, actinomicozis, Crohn s disease, lymphoma, Ameboma Barium enema and colonoscopy is diagnostic Ovary Tms and cysts Pelvic examination, US, CT Appendix Complications of appendicitis Abscess, Plastrone Small intestine Crohn s disease ( Mass, abdominal pain, weight loss, diarrhea )

24 MID ABDOMEN Particular importance to aorta Prior to rupture asymptomatic Pulsatile mass Bruit US, CT is sufficiently diagnostic Aortography is invasive

25 LEFT LOWER QUADRANT Descending or sigmoid colon Ovary Small intestine Mesentery Omentum Retroperitoneal masses Diverticulitis is the commonest pathology Fecalom Sigmoid colon tms

26 SUPRAPUBIC MASS Bladder Uterus Small intestine, colon, ovary, omentum Generalized Abdominal swelling Bowel obstruction Ascites Big cysts of ovary

Acute abdominal conditions Key Points

7 Acute abdominal conditions Key Points 7.1 ASSESSMENT AND DIAGNOSIS Referred abdominal pain Fore gut pain (stomach, duodenum, gall bladder) is referred to the upper abdomen Mid gut pain (small intestine,