ABDOMINAL MASS, GENERALIZED
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 (see page 2), 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.
ABDOMINAL MASS, GENERALIZED
ABDOMINAL MASS, GENERALIZED
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 where 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 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 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 is suggested as an exercise for the reader. Take each organ system as a tract. Thus, the gastrointestinal 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
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
More About Causes of Swollen spleen
» Next page: Abdominal mass (Handbook of Signs & Symptoms (Third Edition))
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