Right Upper Quadrant Mass

Right Upper Quadrant Mass: Excerpt from Differential Diagnosis in Primary Care

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 226, 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.

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RIGHT UPPER QUADRANT MASS

	M	I	N	T
	Malformation	Inflammation	Neoplasm	Trauma
Skin	Sebaceous cyst	Abscess	Carcinomas (primary or metastatic)	Contusion
Subcutaneous Tissue and Fascia	Hernia	Cellulitis	Metastatic carcinoma Lipoma	Contusion
Muscle		Myositis		Contusion
Liver	Cyst Riedel lobe	Abscess Hepatitis	Carcinoma (primary and metastatic)	Contusion Laceration
Hepatic Flexure of Colon	Diverticulum Malrotation	Diverticulitis Retrocecal appendix	Carcinoma of the colon	Contusion Perforation
Gallbladder and Ducts	Hydrops	Cholecystitis Cholelithiasis	Pancreatic carcinoma Cholangioma Choledochal carcinoma	Contusion
Duodenum		Perforation of ulcer with subphrenic abscess
Pancreas	Pancreatic cyst	Acute and chronic pancreatitis	Carcinoma of the head of the pancreas	Traumatic pseudocyst
Kidney	Renal cyst Hydronephrosis Polycystic kidney	Hydronephrosis Pyonephrosis Perinephric abscess	Wilms tumor Hypernephroma	Contusion Laceration
Adrenal Gland			Neuroblastoma Pheochromocytoma Adrenal carcinoma
Lymph Nodes			Hodgkin lymphoma Metastatic carcinoma

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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.

Approach to the Diagnosis

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.

Other Useful Tests

1. Amylase and lipase levels (pancreatic carcinoma, pancreatic cysts)
2. Barium enema (colon carcinoma)
3. Cholecystogram (gallstones)
4. Gallium scan (subphrenic abscess)
5. Aortogram (aortic aneurysm)
6. Small-bowel series (tumor)
7. Gastroenterology consult
8. Exploratory laparoscopy

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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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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