ABDOMINAL MASS

History: Changes in bowel habits, weight loss, abdominal pain, age of patient, sex, hx of
inflammatory bowel disease/cancer. Sx of liver, renal gallbladder or intestinal disease.
Physical: Location, well-defined or just increase in abdominal girth, does the mass move with
respiration (most upper organs will move down with inspiration but fixed organs like the aorta or
pancreas or masses of the abdominal wall won’t), visible peristalsis. Auscultation for bowel
sounds, bruits or rubs over the mass. Palpation/Percussion to determine if it is fluid or air filled
or solid, surface texture, is the mass firm/hard/soft, is it pulsatile. Other signs of liver disease etc.
Diagnostic Tests: Generally US is useful, especially for renal and liver masses. GI
series/endoscopy/CT with oral contrast (or enema) is useful if GI mass is suspected.

Right Upper Quadrant

1. Liver
a. Moves downward with inspiration. Enlarged and smooth suggests fatty
infiltration. Enlarged, irregular and nodular suggests cirrhosis. Enlarged left lobe
of the liver can be felt in the epigastric area. Venous hum also suggests cirrhosis.
b. Causes of smooth hepatomegaly: congestion due to cardiac failure, micronodular
cirrhosis, reticuloses, hepatic vein obstruction (Budd-Chiari syndrome), infective
hepatitis, cholangitis. portal pyaemia, amyloidosis
c. Causes of knobbly hepatomegaly: liver mets, macronodular cirrhosis, polycystic
disease
d. Causes of localized mass in the liver: Riedel's lobe (normal variant- projection
from inferior right lobe), hydatid cyst, liver abscess, hepatocellular carcinoma
2. Right Kidney
a. May protrude anteriorly when enlarges, but usually a flank mass/in paracolic
gutter. Not dull to percussion. Can be felt bimanually and balloted. Usually only
lower border is palpable.
b. Ddx of flank mass: hydronephrosis, pyonephrosis, perinephric abscess,
hypernephroma, nephroblastoma, solitary cyst, polycystic disease
3. Gallbladder
a. Oval-shaped, moves down with inspiration. Usually smooth and regular. Can’t
feel space between mass and liver. Felt below tip of right 9th rib.
b. Murphy’s sign suggests acute cholecystitis
c. Courvoisier's sign- painless palpable gallbladder suggests pancreatic cancer
d. Charcot’s triad- RUQ pain, jaundice, fever= cholangitis
e. Reynold’s pentad- Charcot’s plus hypotension and confusion= cholangitis plus
shock
4. Colon
a. Deep and ill-defined mass. Does not move with inspiration. High pitched BS
suggest obstruction
b. Ddx: obstruction, inflammatory bowel disease, volvulus
Left Upper Quadrant
1. Spleen
a. Moves downward with inspiration. Extends toward RLQ when enlarged because
of oblique longitudinal axis. Has a medial notch and a sharp edge.
b. Causes of splenomegaly:
i. Infection: Bacterial - typhoid, typhus, TB; Viral - glandular fever;
Protozoal - malaria, kala-azar
 ii. Cellular proliferation: myeloid and lymphatic leukaemia, pernicious
anemia, polycythaemia rubra vera, spherocytosis, thrombocytopenia
purpura, myelosclerosis
iii. Congestion: portal hypertension, hepatic vein obstruction, congestive
heart failure
iv. Other: amyloidosis, Gaucher's disease, Felty's syndrome, angioma,
lymphosarcoma
2. Left Kidney- see above for signs and differential of kidney/flank mass
3. Colon/Pancreas/Stomach- difficult to differentiate on physical exam, rely on history.
a. Pathology may be inflammatory, neoplastic, cystic etc

Right Lower Quadrant

1. Lower GI tract
a. These deeper organs are usually ill defined. History is important.
b. Colon: appendicitis, appendiceal abscess, colon cancer (cecal, painless),
inflammatory bowel disease (painful)
2. Pelvic Organs- bimanual palpation is preferred method of exam
a. Ovarian cyst: smooth mass arising from the pelvis, mobile from side-to-side but
not up and down, dull to percussion, palpable fluid thrill, lower extremity can be
felt on pelvic examination
i. Other causes of ovarian mass: ovarian cancer, Krukenberg tumor,
ovarian fibroids, endometriosis/chocolate cyst, dermoid cyst
b. Tubal mass: hydrosalpinx, endometriosis, PID, tubal pregnancy, fimbrial cyst,
c. Uterine mass: pregnancy, fibroids
d. Pelvic cavity: pelvic abscess, endometriosis
e. Bladder: hemi-ovoid smooth mass arising from the pelvis, can extend above
umbilicus, non-mobile and dull to percussion, does not bulge into the pelvis, can
not be felt on rectal examination.
i. Ddx: bladder distention due to obstruction/retention, cancer
3. Causes of right iliac fossa mass: appendicitis, TB, carcinoma of the caecum, Crohn's
disease, iliac lymphadenopathy, psoas abscess

Left Lower Quadrant

1. Same as right lower quadrant- differentiate between lower GI (diverticulosis) and pelvic
organs.

Midline/Diffuse

1. Midline: Abdominal Aortic Aneurysm rupture- pulsatile mass, abdominal pain,

hypotension. Surgical emergency
2. Diffuse: Ascites, sarcomas etc
3. Mesenteric cyst
Abdominal Wall

1. Abdominal wall masses can be distinguished from intra-abdominal masses by having the
pt tighten the abdominal muscles.
2. Hernias- ventral, direct, umbilical etc
3. Way too many: endometriosis, AV malformation, hematoma, torn abdominal muscle,
Diastasis recti, metastatic cancer (ovarian, pancreatic, myxoid etc all can seed to
abdominal wall with tumor), lipomas, sarcomas, etc etc etc!!