This is where anatomy comes in. In the abdominal wall, there may be an accumulation of fat obesity. The liver may be enlarged by neoplasm or obstruction of its vascular supply e. The spleen may become massively enlarged by hypertrophy, hyperplasia in Gaucher disease, infiltration of cells in chronic myelogenous leukemia and myeloid metaplasia, or by inflammation in kala-azar. The kidney rarely enlarges to the point at which it causes a generalized abdominal swelling in hydronephrosis, but a Wilms tumor or carcinoma may occasionally become extremely large.
The bladder , as mentioned above, may be enlarged sufficiently to present a generalized abdominal swelling when it becomes obstructed, but a neoplasm of the bladder will not present as a huge mass. The uterus presents as a generalized abdominal mass in late stages of pregnancy, but ovarian cysts should be first considered in huge masses arising from the female genital tract. Pancreatic cysts and pseudocysts are possible causes of a generalized abdominal swelling, although they are usually localized to the right upper quadrant RUQ or epigastrium.
It would be unusual for an aortic aneurysm to grow to a size sufficient to cause a generalized abdominal mass, but it is frequently mentioned in differential diagnosis texts. The above method is one method of developing a differential diagnosis of generalized abdominal swelling or mass.
Relying solely on anatomy and cross-indexing the various structures with the mnemonic MINT is another. This mnemonic is suggested as an exercise for the reader. Take each organ system as a tract. Thus, the gastrointestinal GI tract presents most commonly with a diffuse swelling in intestinal obstruction and paralytic ileus; the biliary tract and pancreas with hepatitis, neoplasms, and pancreatic pseudocysts.
The female genital tract may be the cause of a huge abdominal mass in ovarian cysts, neoplasms, and pregnancy. Apply the same technique to the spleen and abdominal wall to complete the picture. There are, in addition, certain conditions that cause abdominal swelling that is more apparent than real.
Lumbar lordosis causes abdominal protuberance, as does visceroptosis. A huge ventral hernia or diastasis recti may mimic an abdominal swelling. Psychogenic protrusion of the belly by straining is another cause.
What can be done to work up a diffuse abdominal swelling? It is important to catheterize the bladder if there is any question that this may be the cause.
A flat plate of the abdomen and lateral decubiti and upright films will help in diagnosing intestinal obstruction, a ruptured viscus, or peritoneal fluid. A pregnancy test must be done in women of childbearing age. If pregnancy or ovarian cysts can be definitively excluded by ultrasonography, then a computed tomography CT scan or diagnostic peritoneal tap may be helpful in the diagnosis. Amylase and lipase levels pancreatic pseudocyst.
Laparoscopy ovarian cysts, metastatic carcinoma, tuberculous peritonitis. When the clinician lays his or her hand on the RUQ and feels a mass, he or she should visualize the anatomy and the differential diagnosis should become clear. Proceeding from the skin, the physician encounters the subcutaneous tissue, fascia, muscle, peritoneum, liver, hepatic flexure of the colon, gallbladder, duodenum, pancreas, kidney, and adrenal gland. The blood vessels and lymphatics to these organs and the bile and pancreatic ducts should be considered.
Then, because masses are caused by a limited number of etiologies, apply the mnemonic MINT to each organ. The differential using these methods is developed in Table 1. Skin malformations do not usually cause a mass, but inflammation of the skin is manifested by cellulitis and carbuncles, and neoplasms are manifested as carcinomas, both primary and metastatic.
Trauma of the skin is usually manifested by obvious contusions or lacerations. A mass of the subcutaneous tissue may be a lipoma, fibroma, metastatic carcinoma, cellulitis, or contusion. A mass disease of the fascia is usually the result of a hernia. The causes of hepatomegaly are reviewed on page , but if the mass is in the liver, it is usually hepatitis, amebic or septic abscess, carcinoma primary or metastatic , contusion, or laceration. A Riedel lobe should not be mistaken for a large gallbladder.
The hepatic flexure of the colon may be enlarged by diverticulitis, carcinoma, granulomatous colitis, contusion, or volvulus. Malrotation may cause a mass in infants. A retrocecal appendix should not be forgotten here either. An enlarged gallbladder accounts for the mass in the RUQ in many cases. The enlargement may be caused by cholecystitis, obstruction of the neck of the cystic duct by a stone causing gallbladder hydrops, Courvoisier—Terrier syndrome caused by obstruction of the bile duct by carcinoma of the head of the pancreas, or cholangiocarcinoma.
The pancreas may be enlarged in M—Malformations by congenital or acquired pancreatic cysts, I—Inflammation of an acute or chronic pancreatitis, N—Neoplasm , and T—Traumatic pseudocysts. A duodenal diverticulum is not usually felt as a mass, but a perforated duodenal ulcer may manifest itself by a palpable subphrenic abscess in the right anterior intraperitoneal pouch. Malformations of the kidney often cause hydronephrosis, whereas inflammation may cause a perinephric abscess and thus an RUQ mass.
Carcinoma or Wilms tumor of the kidney is frequently responsible for a large kidney. Carcinoma of the adrenal gland is not usually palpable until late in the disease process, but a neuroblastoma is palpable early. Other lesions of the adrenal gland are not usually associated with a mass. Aneurysms, emboli, and thromboses of the vessels supplying these organs usually do not produce a mass, but a thrombosis of the hepatic vein the well-known Budd—Chiari syndrome causes hepatomegaly, and emboli and thrombi of the mesenteric vessels of the colon may cause focal enlargement from obstruction and infarction.
Visualizing the lymphatics should recall Hodgkin lymphoma in the portal area. Acute onset of the RUQ mass with a history of trauma is no doubt a laceration or contusion of the liver or kidney: A surgeon should be consulted immediately.
When an RUQ mass is discovered unexpectedly or during a routine physical examination, one may proceed more deliberately.
Ultrasonography will help determine if the mass is a gallbladder, liver, or pancreatic cyst. A CBC, chemistry profile, and liver panel will help determine if the mass is hepatic in origin.
An intravenous pyelogram IVP , urinalysis, or urine culture will help determine if it is renal in origin. However, a CT scan can resolve the dilemma quickly in most cases so it may be the most cost-effective approach. Then, one can determine which specialist to refer the patient to without hesitation. It is important to remember that whereas most masses will require referral to a specialist, fecal impactions and abdominal wall hematomas can be handled by the primary care physician.
Amylase and lipase levels pancreatic carcinoma, pancreatic cysts. A year-old white man who complained of mild weight loss and loss of appetite for 3 months is found to have an RUQ mass on examination. Question 1. Utilizing the methods described above, what is your list of possibilities at this point?
Your physical examination also reveals icteric sclera, clay colored stools, and slight hepatomegaly. Question 2. What is your differential diagnosis now? The anatomy is similar: Just replace the liver with the spleen and the gallbladder with the stomach.
The presence of the aorta on the side of the abdomen should not be forgotten. Again, anatomy is the key, as shown in Table 2. Cross-index the various organs and tissues with the etiologies using MINT as the mnemonic. Gastric dilatation of the stomach is caused by obstruction or pneumonia. Cysts are common for the pancreas, just as polycystic disease, single cysts, and hydronephrosis are common for the kidney.
There is no common malformation for the adrenal gland. In the spleen, a host of systemic inflammatory lesions can cause enlargement see page , but primary infections of the spleen are unusual. The colon may be inflamed by diverticulitis, granulomatous colitis, and, occasionally, by tuberculosis. Inflammatory disease of the stomach does not usually produce a mass, but if an ulcer perforates or if a diverticulum ruptures, a subphrenic abscess may form in the left hypochondrium.
Inflammatory pseudocysts may form in the tail of the pancreas. A palpable perinephric abscess and an enlarged kidney from acute pyelonephritis or tuberculosis may be felt, but inflammatory lesions of the adrenal gland are rarely palpable. Carcinoma of the stomach or colon, Hodgkin lymphoma, chronic leukemias involving the spleen, Wilms tumor, carcinoma of the kidney, and neuroblastoma must be considered. A retroperitoneal sarcoma is occasionally responsible for an LUQ mass.
Less common traumatic lesions here include contusion of the muscle and perforation of the stomach or colon. It should be noted that the left lobe of the liver may project into the LUQ; therefore, tumor and abscess of the liver must be considered.
The presence or absence of other symptoms and signs is the key to the clinical diagnosis of an LUQ mass. The presence of jaundice would suggest that the mass is a large spleen. The presence of blood in the stool would suggest carcinoma of the colon.
The presence of hematuria would suggest that the mass is renal in origin. An enema should be done to exclude fecal impaction before an extensive workup is performed. A conservative workup will include a CBC, sedimentation rate, urinalysis, chemistry panel, platelet count, stool for occult blood, coagulation profile, and a flat plate of the abdomen. On the basis of these results, the clinician can determine whether to do an upper GI series, barium enema, IVP, or CT scan of the abdomen.
Another approach would be to do the CT scan immediately. In the long run, the latter approach may be more cost-effective. It is usually prudent to get a surgical or gastroenterology consult to help decide between the two approaches. Amylase and lipase levels pancreatic pseudocyst or tumor.
Sonogram renal cyst, pancreatic cyst. Anatomy is once again the key to developing a differential diagnosis of a right lower quadrant RLQ mass. Underneath the skin, subcutaneous tissue, fascia, and muscle, lie the cecum, appendix, terminal ileum, iliac artery and vein, and ileum. In the female, the fallopian tube and ovary should be included. Occasionally a ptosed kidney also will be felt here.
Now, apply the etiologic mnemonic MINT to each organ, and you should have a reliable differential diagnosis, like that in Table 3. The important lesions to remember here are the following:. The lymph nodes may be involved with tuberculosis or actinomycosis. The cecum may also be enlarged by accumulation of Ascaris or other parasites. The omentum can contribute to adhesions of the bowel to form a mass, or it may develop cysts. As with other abdominal masses, it is important to look for other symptoms and signs that will help determine the origin of the mass.
If there are fever and chills, an appendiceal or diverticular abscess is possible. Blood in the stool suggests a diagnosis of colon carcinoma. If there is amenorrhea or vaginal bleeding in a woman of childbearing age, an ectopic pregnancy must be considered.
A long history of chronic diarrhea with or without blood in the stools suggests Crohn disease. Diverticulitis Granulomatous colitis Parasites Amebiasis Ulcerative colitis. The initial workup will include a CBC, sedimentation rate, chemistry panel, stool for occult blood, pregnancy test, and flat plate of the abdomen. If there is fever and an acute presentation, consultation with a general surgeon to consider an immediate exploratory laparotomy is indicated.
With a more insidious onset of the RLQ mass, the clinician has a choice of ordering a CT scan of the abdomen and pelvis after performing the initial diagnostic studies or proceeding systematically with a barium enema, IVP, or small-bowel series to determine the origin of the mass. A gastroenterology or gynecology consult may be the best way to resolve this dilemma.
Peritoneal tap ruptured ectopic, peritoneal abscess. A year-old white boy complained of sore throat, fever and chills, and nausea and vomiting for 3 days. On examination, he was found to have an RLQ mass. Utilizing the methods described above, what is your list of possible causes at this point? There is mark tenderness and rebound over the mass. Laboratory evaluation showed a white blood cell WBC count of 18, with a shift to the left. A peritoneal tap revealed mucopurulent fluid.
What are your diagnostic possibilities now? To quickly develop a list of etiologies of a left lower quadrant LLQ mass, visualize the anatomy of the area. Compared to the RUQ, the number of organs there is few. Beneath the skin, subcutaneous tissue, fascia, and muscle are the sigmoid colon, the iliac artery and veins, the aorta, and the ileum.
In the female, one must remember the fallopian tube and ovary. Occasionally, the kidney drops into this region nephroptosis and the omentum may cause adhesion.
Now apply the mnemonic MINT to each organ and the list of possibilities in Table 4 is completed without any difficulty. Lesions of the skin and fascia are similar to those in upper quadrants with one exception: Because of the inguinal and femoral canals, hernias especially indirect inguinal hernias are much more frequent.
In the sigmoid colon the following conditions should be considered:. There may be hematomas of the muscle, trichinosis or cysticercosis, nonarticular rheumatism, or fibromyositis. Muscle cramping from low sodium or other electrolyte disturbances must be considered. The superficial and deep veins are the site of thrombophlebitis, a prominent cause of leg pain. The arteries may be involved by emboli from auricular fibrillation, acute myocardial infarction, and subacute bacterial endocarditis , thrombosis especially in Buerger disease and blood dyscrasias , and vasculitis from arteriosclerosis and collagen diseases.
Acute trauma to the artery or veins may cause pain. As usual, when one moves centrally along the arterial pathways additional causes of pain come to mind. Leriche syndrome and dissecting aneurysm must be considered. When superficial or deep infections of the leg spread to the lymphatics, lymphangitis is important in the differential. The nerves may be involved locally, centrally, or systemically. Buerger disease, cellulitis, and osteomyelitis may involve the nerve locally. Neuromas may occasionally cause focal pain in the distribution of the nerve involved.
More important are the central causes of nerve pain in the limbs. Probably herniated discs of the lumbar spine account for most of these cases, but Pott disease, lumbar spondylosis osteoarthritis? Pelvic inflammatory disease and obturator hernias may rarely involve the obturator nerve. Meralgia paresthetica from diabetes mellitus and other causes must be considered in thigh pain and in causalgia.
Finally, the thalamic syndrome and diseases of the cervical spine must be considered. Dissecting the limb layer by layer, we finally reach the bone , which suggests osteomyelitis, bone tumors, Osgood—Schlatter disease, tuberculous osteomyelitis, and Paget disease. Systemic diseases that may involve the nerves causing pain in the legs include tabes dorsalis, periarteritis nodosa, diabetes mellitus, metabolic and nutritional neuropathies, and blood dyscrasias. The approach to the diagnosis of leg pain involves numerous ancillary examinations that one may not routinely do.
Thus, arterial pulses must be checked all the way up.
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