Abdominal Mass, Generalized
Abdominal Mass, Generalized: Excerpt from Differential Diagnosis in Primary Care
As the physician examines the abdomen, how can he or she recall all of
the causes of a mass or swelling? The physician should consider the
possibilities for the mass’s composition. It may be air, in which case
the physician would think of air in the peritoneum with rupture of a viscus,
particularly a peptic ulcer; or it may be air in the intestinal tract from
focal or generalized distention, in which case the physician would recall
gastric dilatation, intestinal obstruction related to numerous causes , or paralytic ileus.
The mass may be fluid, in which case the physician would recall fluid
in the abdominal wall (anasarca), the peritoneum (ascites, page 3) and its various causes, and fluid
(urine) accumulation in the bladder or intestine or cysts of other abdominal
organs. The latter brings to mind ovarian, pancreatic, and omental cysts.
The mass may be blood in the peritoneal wall, the peritoneum, or any
of the organ systems of the abdomen. The mass may be a solid inorganic
substance, such as the fecal accumulation in celiac disease and
Hirschsprung disease. Finally, the mass may be a hypertrophy,
swelling, or neoplasm of any one of the organs or tissues in the
abdomen.
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.g., Budd–Chiari syndrome or
cardiac cirrhosis) or by obstruction of the biliary tree with neoplasms or
biliary cirrhosis. 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 urinary tract presents with a diffuse “mass” in
bladder neck obstruction. 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.
Approach to the Diagnosis
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.
Other Useful Tests
-
Complete blood count (CBC)
-
Amylase and lipase levels (pancreatic pseudocyst)
-
Liver profile (ascites)
-
Laparoscopy (ovarian cysts, metastatic carcinoma, tuberculous
peritonitis)
-
Lymphangiogram (retroperitoneal sarcoma)
-
Surgery consult
-
Gynecology consult
-
Exploratory laparotomy
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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