teaching plan 4

What’s the problems of these What’s the problems of these patients??patients??

Abdominal massesAbdominal masses

overviewoverview

• Not easy to be detected by patient Not easy to be detected by patient himselfhimself

• Usually detected by routine physical Usually detected by routine physical examinationexamination

• Most of them develop slowlyMost of them develop slowly

• crypticcryptic

overviewoverview

Abdominalmass

abscess

Problem with a blood vessel

Enlarged Organ

(spleen,kidney,

liver etc.)

tumorAccumulation

of feces

Symptoms and signsSymptoms and signs

SymptomsSymptoms

Abdominal aortic aneurysmAbdominal aortic aneurysm

• Pulsating mass around navelPulsating mass around navel

aneurysmaneurysm

postoperationpostoperation

Bladder distentionBladder distention

• Firm mass in the Firm mass in the center of lower center of lower abdomen above abdomen above pelvic bonespelvic bones

• Some can extend Some can extend as far up as navelas far up as navel

cholecystitischolecystitis

• Tender mass felt below the liver in RUQTender mass felt below the liver in RUQ

COLON CANCERCOLON CANCER

• Mass anywhere in abdomenMass anywhere in abdomen

Crohn’s disease or bowel obstrucCrohn’s disease or bowel obstructiontion• Multiple tender, sausage-shaped massesMultiple tender, sausage-shaped masses

diverticulitisdiverticulitis

• Mass located Mass located in LLQin LLQ

Gallbladder tumorGallbladder tumor

• Moderately tender, irregularly Moderately tender, irregularly shaped mass in RUQshaped mass in RUQ

hydronephrosishydronephrosis

• Smooth , Smooth , spongy-feeling spongy-feeling mass mass

• In one or both In one or both sides or toward sides or toward the backthe back

Kidney cancerKidney cancer

• Sometimes a mass in abdomenSometimes a mass in abdomen

Liver cancerLiver cancer

• A firm, lumpy mass in RUQA firm, lumpy mass in RUQ

Liver enlargement (hepatomegalLiver enlargement (hepatomegaly)y)• Firm, irregular mass below right rib cage Firm, irregular mass below right rib cage

(right costal margin)(right costal margin)• Or on the left side in stomach area (epigOr on the left side in stomach area (epig

astric)astric)

neuroblastomaneuroblastoma

• Malignant tumorMalignant tumor• In lower abdomenIn lower abdomen• Occurs in children and in fantsOccurs in children and in fants

Ovarian cystOvarian cyst

• Smooth, rounded, rubbery mass Smooth, rounded, rubbery mass above pelvis in lower abdomen above pelvis in lower abdomen

Pancreatic abscessPancreatic abscess

• Mass in epigastric area of upper abdomeMass in epigastric area of upper abdomenn

Pancreatic pseudocystPancreatic pseudocyst

• Lumpy mass in epigastric area of upper Lumpy mass in epigastric area of upper abdomenabdomen

Renal cell carcinomaRenal cell carcinoma

• Smooth, firm, nontender mass near (usuSmooth, firm, nontender mass near (usually one side)ally one side)

Spleen enlargement (splenomegaSpleen enlargement (splenomegaly)ly)• Edge of enlarged spleen felt in LUQEdge of enlarged spleen felt in LUQ

Stomach cancerStomach cancer

• Mass in epigastric area of left-upper abdMass in epigastric area of left-upper abdomenomen

Uterine leiomyoma (Uterine leiomyoma ( 平滑肌瘤平滑肌瘤 ))

• Round, lumpy mass above pelvis in Round, lumpy mass above pelvis in the lower abdomenthe lower abdomen

Volvulus Volvulus

• A mass anywhere in abdomenA mass anywhere in abdomen

Ureteropelvic junction obstructioUreteropelvic junction obstructionn• A mass in lower abdomenA mass in lower abdomen

signssigns

• 4 quadrants: RUQ, RLQ, LLQ, LUQ4 quadrants: RUQ, RLQ, LLQ, LUQ• PeriunbilicalPeriunbilical• Epigastric: area in the center of abdomeEpigastric: area in the center of abdome

n below the ribcagen below the ribcage

diagnosisdiagnosis

history

location Time pattern other

locationlocation

• Upper abdomen? Upper abdomen? RUQ? LUQ? Upper-RUQ? LUQ? Upper-middle area?middle area?

• Lower abdomen? RLQ? LLQ? Lower abdomen? RLQ? LLQ?

• Around navel?Around navel?

• In the groin? (inguinal)In the groin? (inguinal)

Time patternTime pattern

• How long ago was it noticed?How long ago was it noticed?

• Come and go?Come and go?

• How often have you seen it?How often have you seen it?

otherother

• Changes in size, position, extent of Changes in size, position, extent of discomfort, or in any other way?discomfort, or in any other way?

Differential diagnosisDifferential diagnosis

DifferentiationDifferentiation

• Huge ovarian cystHuge ovarian cyst √√ a large area of a large area of dullness at dullness at

midabdomenmidabdomen √√ tympany at lateralstympany at laterals (bow (bow

els could be pushed to the els could be pushed to the bilateral flanks) bilateral flanks)

√ √ The dullness of ovarian cyThe dullness of ovarian cyst could not shiftst could not shift..

DifferentiationDifferentiation

• Ruler pressing testRuler pressing test √√ to differentiate huge ovariato differentiate huge ovaria

n cyst from real ascitesn cyst from real ascites √√ take the supine position, a htake the supine position, a h

ard ruler on the patient’s aard ruler on the patient’s abdominal wall horizontally, bdominal wall horizontally, presses the ruler downward presses the ruler downward with two handswith two hands

DifferentiationDifferentiation

• If huge ovarian cyst exists, If huge ovarian cyst exists, the pulsation of abdominal the pulsation of abdominal aorta will conduct to the aorta will conduct to the ruler via the cyst, leading to ruler via the cyst, leading to rhythmic pulsation of the rhythmic pulsation of the hard ruler.hard ruler.

• If free fluid, not cyst, exists If free fluid, not cyst, exists in the abdominal cavity, the in the abdominal cavity, the pulsation of abdominal pulsation of abdominal aorta could not conduct, so aorta could not conduct, so the hard ruler has no such the hard ruler has no such rhythmic pulsation.rhythmic pulsation.

DifferentiationDifferentiation

• pregnancypregnancy

√√ breast engorged breast engorged

√√ fetal movement fetal movement and parts may be and parts may be feltfelt , , fetal heart fetal heart should be audibleshould be audible

√ √ cervix softenedcervix softened

DifferentiationDifferentiation

• cecumcecum √√ cecum felt: indistinct soft cecum felt: indistinct soft

mass, slightly tender, fluctmass, slightly tender, fluctuant uant

firmer mass felt:firmer mass felt: √√ tuberculous granulomatuberculous granuloma √ √pericecal or appendiceal apericecal or appendiceal a

bscessbscess √√crohn diseasecrohn disease √ √carcinomacarcinoma

DifferentiationDifferentiation

• fecesfeces √√ irregular plastic irregular plastic

masses of feces may masses of feces may be palpated in be palpated in sigmoidsigmoid

√ √ it can move or it can move or disappear in 1 or 2 disappear in 1 or 2 days days

DifferentiationDifferentiation

• EnlargeEnlarged d

kidneykidney

Enlarged Enlarged kidneykidney

congenitalInflammatory/

immuneMechanical/

traumaneoplastic

DifferentiationDifferentiation

• Enlarged kidney--Enlarged kidney--congenitalcongenital √√ polycystic kidney diseasepolycystic kidney disease √√ horseshoe kidneyhorseshoe kidney √ √compensatory ypertrophy ocompensatory ypertrophy o

pposite absent kidneypposite absent kidney √√idiopathic. Cyst(idiopathic. Cyst( 先天性的，先天性的，

特发的）特发的）

DifferentiationDifferentiation

• Enlarged kidney--Enlarged kidney--Inflammatory/immune

√ √ amyloidosis amyloidosis (( 淀粉样变性）淀粉样变性）

DifferentiationDifferentiation

• Enlarged kidney-- Enlarged kidney-- Mechanical/trauma √ √ hydronephrosis hydronephrosis √√ hematomahematoma

DifferentiationDifferentiation

• Enlarged kidney-- Enlarged kidney-- neoplastic √ √ renal cell carcinomarenal cell carcinoma √√ renal sarcoma (renal sarcoma ( 肉瘤肉瘤 )) √ √transitional cell carcinoma of retransitional cell carcinoma of re

nal pelvis and ureternal pelvis and ureter

DifferentiationDifferentiation

• Enlarged kidneyEnlarged kidney √ √ lacks the sharp edge the spleen and liver malacks the sharp edge the spleen and liver ma

y presenty present √√ lobulation of kidney may be mistaken for splobulation of kidney may be mistaken for sp

enic notchenic notch √ √enlarged kidney may be more often irregulaenlarged kidney may be more often irregula

r than spleenr than spleen √ √renal mass do not move with deep inspiratorrenal mass do not move with deep inspirator

y effort, unlike spleen and liver, because of rey effort, unlike spleen and liver, because of retroperitoneumtroperitoneum

Other abdominal massOther abdominal mass

• VolvulusVolvulus• IntussusceptionIntussusception• AbscessAbscess• Enlarged tender gallbladderEnlarged tender gallbladder• Distended urinary bladderDistended urinary bladder• Abdominal, inguinal, and other herniaAbdominal, inguinal, and other hernia

Enlarged tender gallbladderEnlarged tender gallbladder

• Progressive enlargement of the gallbladder--obstProgressive enlargement of the gallbladder--obstruction of common bile ductruction of common bile duct

• Nontender gallbladder—stones, acalculous choleNontender gallbladder—stones, acalculous cholecystitis, gallbladder hydropscystitis, gallbladder hydrops

• Contracted gallbladder—chronic cystic duct obstContracted gallbladder—chronic cystic duct obstructionruction

• Dilatation of gallbladder—carcinoma of the head Dilatation of gallbladder—carcinoma of the head of pancreas but not with common duct stoneof pancreas but not with common duct stone

• Hard, irregular mass, tender—carcinoma of gallblHard, irregular mass, tender—carcinoma of gallbladderadder

Distended urinary bladderDistended urinary bladder

• In midline, may reach the umbilicusIn midline, may reach the umbilicus

• Dull to percussionDull to percussion

• FluctuantFluctuant

• PainlessPainless

• Disappears wit catheterizationDisappears wit catheterization

Abdominal, inguinal, and other Abdominal, inguinal, and other herniahernia

• Abdominal heaniaAbdominal heania: : Incisional heniaIncisional henia• Operative scarOperative scar• Defect in abdominal wallDefect in abdominal wall• Valsalva maneuver or raise head while sValsalva maneuver or raise head while s

upine: herniation occurs adjacent to the upine: herniation occurs adjacent to the scar scar

Luxembourg