Gastrointestinal Surgery Abdominal Mass Iliac Fossa Diagnosis Umbilical Region Notes

Abdominal Mass Introduction

• The abdomen is like Pandora’s box. However, a student who is examining a case of abdomen is like an investigating CBI officer.
• He has to collect information at every level of examination, i.e. history, past history, general examination and abdominal examination. An attempt has been made here to highlight the importance of history and clinical examination.

Read And Learn More: Gastrointestinal Surgery Notes

• Ten points in the history, if taken and analysed properly may give a definite clue in the majority of cases. After getting this clue, clinical examination of the mass may become easy.

Clinical Examination Of Abdominal Mass Regions In The Abdomen

• The abdomen is divided into nine regions (quadrants) by two horizontal lines and two vertical lines.
• The upper horizontal line or transpyloric line is midway between the xiphisternum and umbilicus.
• The lower horizontal line (transtubercular line) is the line joining the iliac crest tubercles of each side, about 5 cm behind the anterior superior iliac spine.
• The vertical lines are drawn on either side through the midpoint between the anterior superior iliac spine and the symphysis pubis.

Following are the nine regions of the abdomen.

1. Right hypochondrium
2. Epigastrium
3. Left hypochondrium
4. Right lumbar region
5. Umbilical region
6. Left lumbar region
7. Right iliac fossa
8. Hypogastrium
9. Left iliac fossa

Abdominal Mass History

1. Abdominal Pain:

It Is Present In Most Of The Cases Of Abdominal Mass. Abdominal Pain Can Be Of The Following Types

1. Dull aching pain: It suggests a solid organ enlargement. It is a continuous pain felt in the anatomical location of the swelling. Patients often describe it as a discomfort rather than pain.
   • Examples
   • Liver enlargement: Pain in the right hypochondrium. It occurs due to stretching of the parietal capsule (Glisson’s)
   • Splenic enlargement: Pain in the left hypochondrium
   • Renal enlargement: Pain in the back and coastal region or costovertebral pain
   • Enlarged lymph nodes (para-aortic), pancreatic tumours: Backache
2. Colicky pain suggests hollow viscus obstruction.
   • This pain is due to hyperperistalsis. It is severe and intermittent (comes and goes). Each attack may last for 5–10 minutes. The patient bends on himself, holds the abdomen and puts pressure on the abdomen which gives some kind of relief.
   • Being the visceral type of pain, it is not very well localise Following are a few examples:
   • Mass in the right iliac fossa (carcinoma caecum or ileocaecal tuberculosis). Initially, there may be a vague discomfort.
   • However, when partial obstruction occurs, it results in colicky abdominal pain which is centrally located and sometimes unbearable.
   • Ureteric colic and biliary colic.
   • Carcinoma pyloric antrum or pyloric stenosis produces colicky upper abdominal pain with gastric peristalsis. However, this type of pain is not an unbearable one.

Abdominal Mass Referred pain: Tuberculosis of the spine is a common problem in India. Often patients present with iliopsoas abscesses. Patients can complain of referred pain in the lower abdomen.

Recent backache in elderly males may be due to carcinoma prostate and in females may be due to carcinoma breast.

2. Sensation of fullness/early satiety

• Carcinoma of the stomach and pyloric obstruction. Also, hepatoma or large pancreatic tumours can cause extraluminal compression on the stomach resulting in the sensation of fullness in the abdomen.
• Early satiety is due to the loss of receptive relaxation of the stomach due to malignant infiltration of the muscle layer.

3. Vomiting

• Persistent, profuse, projectile and nonbilious vomiting suggests pyloric stenosis. Chronic duodenal ulcer and carcinoma stomach are the common causes of pyloric obstruction (pain is absent/negligible).
• Persistent, profuse, projectile, bilious vomiting— intestinal obstruction. For example, ileocaecal tuberculosis, stricture of the small bowel, and adhesions (pain is severe and colicky).

4. Haematemesis

• Epigastric mass suggests carcinoma stomach.
• Splenomegaly may be an indication of portal hypertension

5. Bleeding per rectum

• Fresh blood with or without melaena— carcinoma rectum
• Melaena—carcinoma stomach, portal hypertension

6. Loss of appetite and loss of weight

• These are common symptoms of GI malignancies. Please note that these two symptoms are seen not only in intra-abdominal malignancies but also in many diseases such as tuberculosis.
• However, it should be noted that one of the earliest signs of carcinoma stomach is loss of appetite. Severe weight loss is an early and important feature of the carcinoma body of the pancreas.
• Significant weight loss refers to a loss of 10 kg or more in the last 6 months.

7. Bowel habits

• Fresh bleeding per rectum: Carcinoma rectum
• Blood and mucus (bloody slime): Carcinoma rectum
• Alternate constipation and diarrhoea: Carcinoma colon

8. Jaundice

• Progressive, persistent, pruritic jaundice: Periampullary carcinoma or carcinoma head of the pancreas. However, in periampullary carcinoma, fluctuation can occur if growth ulcerates.
• Mild recurrent jaundice: Haemolytic anaemia.
• Intermittent jaundice, pain, fever: Charcot’s triad—stone in the common bile duct.

9. Haematuria:

• Fresh bleeding/clots: Renal cell carcinoma.

10. Fever

• High-grade fever, with chills and rigours: Stone in the common bile duct
• Low-grade fever: Hepatoma, renal cell carcinoma, lymphomFever is due to some pyrogens released into circulation or due to tumour necrosis.
• In a tropical country like India, hepatomas with fever are often diagnosed as amoebic liver abscesses and mistreated.

11. Abdominal distension:

• The only chief complaint can be abdominal distension, most often due to ascites.
• In surgical wards, the common cause of ascites in young patients is tuberculous ascites, in middle-aged men is due to cirrhosis (alcohol is the most common cause) and in elderly patients malignancy.
• Large pseudocysts, retroperitoneal tumours, and in females ovarial tumours can present with abdominal distension.
• In the absence of any of these, distension can be caused by retroperitoneal tumours.

On Examination Inspection

• The patient is asked to breathe well with mouth open.
• Students should spend a few minutes watching the abdomen carefully.

1. Shape of the abdomen

• Scaphoid in normal cases
• Protuberant in fatty abdomen.
• Generalised distension with fullness in the flanks is usually due to ascites.
• Localised distension can be due to mass
• The presence of step ladder peristalsis indicates small bowel obstruction, visible gastric peristalsis indicates pyloric stenosis and right to left peristalsis indicates colonic obstruction.

2. Restricted movement of any one region of the abdomen indicates an inflammatory pathology.

3. Umbilical nodule (Sister Joseph’s) indicates intraabdominal malignancy (carcinoma of stomach, colon, pancreas).

4. Details about the mass such as size, shape, surface, borders, and movement with respiration have to be mentioned if a mass is visible.

If the details about the mass cannot be appreciated or if the mass is not clear on inspection, it is better to say “there is fullness” rather than trying to manipulate the details about the mass.

5. Inspection of male genitalia: If the scrotum is empty, it could be a case of undescended testis1,2.

Palpation Methods Of Palpation

Following are the methods of palpation available to the clinician and done depending upon the merits of the case:

1. Superficial palpation: Gentle superficial palpation of the abdomen gains the confidence of the patient. It can detect superficial lesions of the abdominal wall such as lipomatosis, neurofibromas or fibromas, It can also detect an area of tenderness, so the clinician is careful while doing deeper palpation. Superficial palpation is done with the flat of the hand or fingers.
2. Deep palpation: These are important requirements for deeper palpation:
   • The patient should be well-relaxed, with flexion of the knee for about 45°.
   • The patient’s face should be turned to the opposite side and he is asked to breathe comfortably with an open mouth.
   • Deep palpation should be started from the quadrant situated diagonally opposite to the site of pain.
   • Palpation should cover not only the 9 quadrants of the abdomen but also 2 more quadrants, i.e. the 2 renal angles and 12th quadrant—external genitalia in males3.
   • Deep palpation is carried out with the palmar surface of the fingers and some degree of angulation depending upon the depth of palpation.

Palpation Tests

1. Movement with respiration:

• This test is done by placing the fingers (hand) over the lower border of the swelling and the patient is asked to take a deep breath.
• Movement with respiration is positive when there are “up and down” movements not anteroposterior movement. Any structure in contact with the diaphragm moves with respiration.

Palpation For example:

• The liver, stomach, spleen, and gallbladder move very well with respiration.
• Splenic flexure growth, due to contact with the lower pole of the spleen and hepatic flexure growth due to contact with liver move with respiration.
• Renal swelling moves with respiration because the kidney is enclosed by the fascia of Gerota which is attached above the diaphragm.

2. Size, shape and surface

• An egg-shaped mass or globular mass suggests a gallbladder lesion.
• A horseshoe shape may indicate a horseshoe kidney with pathology, e.g. hydronephrosis.
• The reniform shape suggests renal swelling.

Movement with Respiration

• Liver, spleen and stomach masses move freely with respiration
• Gallbladder mass also moves freely with respiration because of its proximity to the liver
• Mass arising from hepatic flexure and splenic flexure of the colon also have some mobility because it is in contact with the liver and spleen
• Renal masses exhibit a minor degree of movement with respiration because of indirect attachment to the diaphragm.

A large nodular surface is seen in the following conditions:

• Polycystic kidney
• Secondaries in the liver
• Group of lymph nodes
• Tensely cystic swellings may feel firm.

Examples: Tense distended gallbladder in cases of obstructive jaundice due to periampullary carcinoma

• A smooth surface usually indicates a benign lesion.
• Splenomegaly, hydronephrosis, ovarian cyst, gallbladder swelling.
• The irregular surface is an important feature of malignancies such as carcinoma of the stomach, and carcinoma caecum.

3. Consistency

• Hardness is a feature of malignant lumps. Thus, hepatoma, carcinoma stomach, and pancreatic carcinoma present as a hard lump. However, it should be remembered that often the malignant lump is firm and not hard.
• Firm consistency is found in ileocaecal tuberculosis, nodes of lymphoma.
• A peculiar doughy feel is described for the tuberculous abdomen.
• It is difficult to elicit fluctuation tests for intraabdominal swellings, and often tense cystic swellings feel firm on palpation, e.g. pseudocyst of the pancreas, hydronephrosis, etc.
• Indentation or pitting on pressure can be found in a colon loaded with faeces.
• Temporary contraction of a stomach (visible gastric peristalsis) should not be confused with a mass.

4. Margins or borders

• The upper border cannot be made out in liver, splenic and renal swellings.
• Lower border is not appreciated in pelvic masses, e.g. uterine fibroid, or ovarian cyst (pelvic).
• A characteristic notch is felt in the anterior border of splenic swelling.
• The lower border is sharp as in a malignant liver swelling.

5. Finger insinuation test: This test has relevance in an upper abdominal mass.

• The liver and spleen are under the right and left costal margins, respectively. Hence, it is not possible to get the upper margin or upper border of these organs.
• An attempt to invaginate between the costal margin and these masses is not possible.
• On the other hand, finger invagination under the costal margin is possible in a stomach mass.

6. Intrinsic mobility test

• An intra-abdominal mass can be mobile if it has loose attachments or if it is not within the bony cage. Thus, the liver, spleen, and uterine mass are not mobile because of their location within the bony cage.

Intrinsic Mobility—Mass

• Side-to-side — Gallbladder
• Vertical — Transverse colon
• All directions — Ovarian cyst
• Right angle to the — Mesenteric cyst direction of the mesentery
• Push back to renal — Kidney pouch
• Treetop mobility — Pancreatic cystadenoma
• Carcinoma pyloric antrum can exhibit movements in different positions—left lateral, right lateral or even in the sitting position.
• Pancreatic carcinoma, advanced malignancies and lymph nodal masses also may not have intrinsic mobility.
• However, there are a few swellings which have characteristic mobility.

Intrinsic Mobility—Mass Examples

1. An ovarian cyst is a freely mobile swelling which can be moved in all directions.
2. The mesenteric cyst moves at right angles to the direction of the line of the mesentery.
3. Pseudopancreatic cysts may have minimal side-to-side mobility.
4. Carcinoma transverse colon has vertical mobility unless it is advanced.
5. Pancreatic masses: Even though they do not exhibit mobility, a cystadenoma of the pancreas because of the size and narrow base, will exhibit tree-top mobility.
6. Any big mass abutting the undersurface of the diaphragm also moves with respiration
7. Renal mass comes down during inspiration. As it comes down, it can be held back and can be pushed back to the renal pouch.

7. Plane of the swelling

1. Leg raising test or head raising test
   • The purpose of this test is to contract rectus abdominis muscles (also other abdominal wall muscles).
   • Intra-abdominal swellings become less prominent. On the other hand, abdominal wall swellings become more prominent, e.g. fibroma, neurofibroma, or lipoma in the abdominal wall.
   • This test is done by asking the patient to raise his legs without bending at the knee (extended legs) or by raising the shoulders from the bed with an arm folded over the chest.
2. Nose blowing test or straining test
   • This test can be done by asking the patient to blow through the nose with mouth closed lateral abdominal muscles are more contracted with this test.
   • It should be remembered that a swelling or the mass which moves with respiration is obviously an intra-abdominal mass.
3. Knee-elbow test
   • This test differentiates an intraperitoneal mass from a retroperitoneal mass. It is more useful when there is a mass in the centre of the abdomen— more so in the upper abdomen.
   • To give a few examples, an intraperitoneal cyst or intraperitoneal mass falls on the other hand, pancreatic mass or a lymph node mass will not fall forward test has significance only in ‘selected’ cases.
   • However, the knee-elbow test helps to differentiate expansile pulsation from transmitted pulsation.
   • Examples: A pseudocyst of the pancreas will give transmitted pulsations because it overlies the aorta in the knee-elbow position, pulsation disappears as it gets separated from the aortOn the other hand, aneurysms exhibit expansile pulsations.
   • Intraperitoneal mass with pulsations over it is likely to be hepatoma Retroperitoneal mass with pulsations over it is pancreatic mass.

Intrinsic Mobility—Mass Special Tests

1. Bimanual palpation: Grossly enlarged swellings may be bimanually palpable such as the liver, spleen, and kidney.

2. Ballotability: ‘Ballot’ means to toss about. To ballot, the swelling should be bimanually palpable and there should be a gap or space between hands which are kept anterior and posterior to the mass.

• Typically, renal swellings are ballotable. This test is done when the patient is in the supine position, by keeping one hand anteriorly in the lumbar region over the swelling and the other hand posteriorly in the renal angle.
• A gentle push is given from behind and the swelling touches the hand which is placed anteriorly and it goes back. Ballotability is because of the perirenal pad of fat and due to ‘pedicle

Renal Ballotability

• Posterior enlargement is more—thus space for movement anteriorly
• Placed peripheral—thus can be felt by both hands
• Pedicled organ—free movement possible
• Perirenal pad of fat—thus cushion effect Ps to remember

3. Splenic dullness: It is elicited in the 9th intercostal space in the left midaxillary line and it is continuous with splenic mass.

• Traube’s space is a semilunar space between the lower edge of the left lung, the anterior border of the spleen, the left costal margin and the inferior margin of the left lobe of the liver.
• Anatomically superiorly bounded by the left sixth rib, laterally by the left midaxillary line and inferiorly by a left costal margin.
• The stomach which is posterior to this space gives a tympanitic note normally but gives a dull note when the spleen is enlarged.

Renal Ballotability Percussion

1. To demonstrate mild ascites, the patient is put in a knee-elbow position and percussion is done around the umbilicus. It gives a dull note if minimal fluid is present (normally area around the umbilicus is resonant).
   • Significant or moderate fluid in the abdomen is demonstrated by percussion of the centre and flanks of the abdomen in the lying down position and in the left or right lateral position.
   • In the supine position, flanks give a dull note due to fluid however, in the lateral position, fluid shifts down and coils of bowel float up.
2. Liver dullness is elicited in the 5th intercostal space and the dullness is continuous with the mass if it is arising from the liver.
3. Splenic dullness is elicited in the 9th intercostal space in the left midaxillary line.
4. Percussion over the mass: Splenic and liver masses classically are dull to percuss.

Renal Ballotability Percussion

• Dull note: Liver, spleen, renal angle
• Resonant: Bowel anterior to the mass (e.g. retroperitoneal mass)
• Impaired: Stomach mass
• Shifting dullness: Ascites

• Retroperitoneal masses may give a resonant note because of the intestines anterior to it.
• However, when they attain a large size, e.g. sarcomas, they push the bowel to one side and hence, they are dull to percuss.
• Stomach mass may give impaired resonant notes because of solid growth and due to the presence of air in the stomach.
• Renal angle percussion: In cases of enlargement of the kidney, there will be a band of resonance anteriorly due to the colon but posteriorly it gives a dull note.
• Hydatid thrill: It is demonstrated by placing 3 fingers over the swelling and percussing the middle finger. Due to the fluid in the cyst, the fluid thrill (after-thrill) is felt by the other two fingers. This clinical sign is rarely demonstrable.

Renal Ballotability Auscultation

• Loud noisy sounds (borborygmi) with or without peristalsis may indicate subacute obstruction. Such patients may be having ileocaecal tuberculosis or carcinoma caecum. This should be done at the right iliac fossa to listen to bowel sounds.
• Auscultation over the liver mass may reveal a bruit as in a rapidly growing hepatoma.
• Succussion splash is a splashing sound in cases of pyloric obstruction either due to carcinoma or chronic duodenal ulcer.
• Perisplenitis and perihepatitis give rise to friction rub as in sickle cell anaemia due to repeated infarction and adhesions.
• Aortic aneurysm will give a continuous murmur in the upper abdomen.
• Auscultopercussion or auscultoscraping test is done to assess the lower border of the stomach or greater curvature of the stomach.

Rectal Examination

This should be done in a case of intra-abdominal mass.

• It can detect a carcinoma or a growth in the rectum in the case of secondaries in the liver.
• It can detect secondaries in the rectovesical pouch. Blumer’s shelf—as hard, nodular mass and rectal mucosa are free during digital examination.

Vaginal Examination

This should be done to rule out carcinoma cervix or to detect lymph nodes in the pouch of Douglas.

Bimanual Examination

This should be done in cases of pelvic masses. One hand (left) is placed over the mass in the hypogastrium and the right index finger or fingers are inserted in the vagina or rectum in virgin females and the left hand is pressed downwards and backwards above the pubic symphysis. By this manoeuvre, details of the pelvic mass, solid or cystic, uterine or ovarian, free or fixed can be made out.

Examination of Lymph Nodes

In cases of abdominal masses arising from lymph nodes, a thorough search of the body should be done to rule out another group of lymph nodes such as axillary, iliac, inguinal, and neck nodes (lymphoma).

Examination of Lymph Nodes Significance

• Left supraclavicular nodes (Virchow’s) are enlarged very often in visceral malignancies mainly from the gastrointestinal tract.
• It indicates the “inoperable” nature of the disease. Entire gastrointestinal lymph drains into the thoracic duct which joins the point of confluence of the internal jugular vein and subclavian vein on the left side.
• This explains the significance of the enlargement of Virchow’s node. In 20% of cases, the thoracic duct is single and in 10–15% of cases, it is double.

Significance of right supraclavicular node:

• The lymphatics from the right mediastinal lymph trunk, and from the posterior right thoracic wall which form the right upper lymph trunk drain into the commencement of the right brachiocephalic vein.

Systemic Examination

• Systemic examination should include the respiratory system and cardiovascular system. Evidence of tuberculosis of the chest gives a clue about the mass in the abdomen, which may be a tubercular mass.

Differential diagnosis: Students are requested to refer to clinical books for details. However, mass arising from five different quadrants is discussed below.

Mass In The Right Iliac Fossa

Parietal Swelling

1. Parietal wall abscess
2. Desmoid tumour

Intra-Abdominal Swelling

1. Arising from normal structures
2. Arising from abnormal structures

From Normal Structures

1. Intestines
   • Appendicular mass
   • Appendicular abscess
   • Ileocaecal tuberculosis
   • Carcinoma caecum
   • Amoeboma
   • Intussusception
2. Actinomycosis
   • Lymph nodes
   • Acute lymphadenitis
   • Lymphoma
   • Secondaries
3. Retroperitoneal structures
   • Sarcoma
   • Aneurysm
   • Iliopsoas abscess
   • Chondrosarcoma
4. In females
   • Ovarian cyst
   • Fibroid
   • Tubo-ovarian mass

From Abnormal Structures

1. Undescended testis: Seminoma
2. Unascended kidney

Differential Diagnosis Of Mass In The Right Iliac Fossa

1. Parietal swelling: They are extra-abdominal. On the head or leg raising test, they become more prominent. They are uncommon swellings.
   • Parietal wall abscess: It is a pyogenic abscess which can occur in a haematoma, or a pyaemic abscess which can occur as a part of pyaemia as in diabetic patients. Such abscesses are very tender, with a warm surface and are associated with fever, chills and rigours.
   • Desmoid tumour: It is an unencapsulated fibroma occurring in the abdominal wall.
     • Occurs in multiparous females. Repeated stretching of abdominal layers (due to pregnancy) is supposed to initiate the formation of a tumour.
     • It can also occur following abdominal wall injury including laparotomy.
     • It is a firm-to-hard swelling.
     • It has no capsule. Hence, it should be treated with wide excision.
     • It does not undergo sarcomatous change.
     • After wide excision, the abdominal wall has to be reconstructed by using mesh.
2. Intra-abdominal swelling
   1. Arising from structures normally present in the right iliac fossa
      1. It is a tender, soft to firm mass which develops within 48–72 hours following acute appendicitis.
      2. It is nature’s attempt to limit the spread of infection by forming a mass consisting of omentum, terminal ileum, caecum with periapical fat and inflammatory oedema
      3. It is managed conservatively by Oschner-Sherren’s regime because an attempt to remove the appendix may result in faecal fistul6–8 weeks later, an elective appendicectomy can be done.
   2. Appendicular abscess: It will be a very tender, firm, fixed mass. Such patients will have a fever with chills and rigours.
   3. Ileocaecal tuberculosis: Hyperplastic variety of tuberculosis forms a chronic cicatrising granulomatous reaction involving the terminal ileum, caecum and part of the ascending colon resulting in a mass in the right iliac foss It is a chronic, non-tender, firm, nodular mass, that may have mobility, situated slightly (lumbar) on the higher side. Features of tuberculosis are usually present. It is treated by limited resection followed by ileocolic anastomosis.
   4. Carcinoma caecum:
      • More common in females, around 40–50 years of age.
      • It produces bleeding per rectum, severe anaemia, etc.
      • Hard, irregular mass in right iliac fossa with fixity or restricted mobility is a usual feature. The Psoas spasm indicates infiltration into the psoas muscle. It is treated by right radical hemicolectomy.
   5. Amoeboma: This can be acute or chronic following an attack of amoebic typhlitis (inflammation of the caecum). Amoeboma is tender and soft to firm. It is not common to find amoebomas nowadays because of the effective treatment of amoebiasis with metronidazole, tinidazole, etc.
   6. Intussusception: Acute or chronic intussusception can give rise to a mass in the right iliac fossa which is tender and soft to firm. When acute intussusception occurs in children, it is described as idiopathic intussusception. Chronic intussusception may disappear spontaneously.
   7. Actinomycosis: This is a rare mass in the right iliac fossa which usually develops 2–3 months after appendicectomy.
      • A woody hard, indurated tender mass with multiple sinuses is characteristic of this condition.
      • Sinuses discharge sulphur granules which can trickle down. Unlike tuberculosis, narrowing of the lumen of the gut and lymph node enlargement does not occur.
   8. Lymph node mass
      • Acute mesenteric lymphadenitis is common in children. It produces tender, nodular and firm mass in the right iliac foss
      • The child usually has a fever. Acute lymphadenitis can also involve external iliac nodes as in filariasis.
      • Lymphoma involving external iliac nodes, nodular, firm to hard mass with involvement of other nodes, liver, spleen, etc.
      • Secondaries in lymph nodes (external iliac) from carcinoma ovary, cervix, and etudes are hard and fixity is a feature.
   9. Retroperitoneal sarcoma
      • Common in young patients
      • Huge, nodular, fixed lump involving lumbar, umbilical and right iliac fossRecent increase in size draws the attention of the patient.
      • Fixed to the posterior abdominal wall
      • Later, obstruction of the inferior vena cava results in oedema of the legs.
      • Pressure on the ureter can give rise to hydronephrosis.
      • Liposarcoma is the commonest and may arise from pre-existing lipoma.
      • Fibrosarcoma, haemangiosarcoma, leiomyosarcoma are other sarcomas.
      • It is treated by wide excision followed by radiotherapy.
      • Chemotherapy is also helpful, when it is not possible to remove the entire mass.
      • Debulking even if it is an advanced case is recommended.
   10. Aneurysm: Iliac artery aneurysm is rare and occurs in old-aged patients. It produces a soft, pulsatile swelling in the right iliac fossBruit or thrill is usually present.
   11. Iliopsoas abscess is the result of tuberculosis of the thoracolumbar spine.
       • It should be suspected when a young patient complains of pain in the back referred to the abdominal wall.
       • Spine movements are limited.
       • Gibbus is present.
       • Initially, it forms a paravertebral abscess and later it gravitates down beneath the medial arcuate ligament and forms a psoas abscess.
       • The Psoas abscess burrows into the thigh under the inguinal ligament and forms an iliopsoas abscess.
       • Fluctuation is present on both sides of the inguinal ligament. It is described as cross fluctuation test.
   12. Chondrosarcoma of the iliac crest: It is a hard, fixed tumour which cannot be separated from the bone.
       1. In females
   13. Ovarian cyst: To start with, the cyst develops in the pelvis and gives rise to discomfort in the lower abdomen. As the cyst grows, it comes out of the pelvis and forms a mass in the right iliac fossIt has a smooth surface, round borders, is cystic freely mobile and can be pushed back into the pelvis. Sometimes, the cyst can attain a huge size. Such freely mobile ovarian cysts have a long pedicle. Per vaginal examination gives the clue to the diagnosis.
   14. Fibroid of the uterus: It presents as a firm to hard nodular mass in the suprapubic region and in the right iliac fossa.
   15. Tubo-ovarian mass
       • It is usually tender
       • Pelvic infection is present
       • It is soft to firm
       • It can be a bilateral

Arising from structures which are not normally present

1. Unascended kidney: It can be either in the pelvis or in the iliac fossSuch kidney is usually not very well-developed and presents as a lobular mass.
2. Normal mobile kidney: It can be felt in the lumbar region, and iliac fossa and can be pushed back into the loin.
3. Undescended testis: It is palpable in the right iliac fossa only when it is involved by Seminom
4. It is an intra-abdominal testis and is a hard, irregular, fixed mass. Absent testis in the scrotum clinches the diagnosis. The patient may have palpable para-aortic nodes, supraclavicular nodes, etc.

Firm To Hard Nodular Mass In The Umbilical Region

1. Mass Arising from Lymph Nodes

1. Metastasis or secondaries
   • Is one of the common lymph node masses in the abdomen. Mass can be due to para-aortic nodes from the testicular tumour, melanoma, carcinoma of the ovary, carcinoma of the pen
   • A para-aortic lymph node mass has the following features:
   • Fixed
   • Does not move with respiration
   • No intrinsic mobility
   • Does not fall forward
   • Coils of the bowel can be felt over the mass
   • Percussion may be resonant because of intestinal coils.
2. Lymphoma: The mass is an enlarged para-aortic group of lymph nodes. It has all the features of the nodes mentioned above. The presence of lymph nodes in the neck along with palpable liver and spleen clinches the diagnosis.
3. Tuberculosis can affect para-aortic nodes. However, it is uncommon.

2. Retroperitoneal Sarcoma

• Common in young patients
• Rapidly growing, enlarging mass in the abdomen of short duration.
• It is firm, hard, nodular, fixed, does not fall forward and has intestinal coils anterior to it.
• Large sarcomas can cause compression on the inferior vena cava or on the ureter. Therefore, pedal oedema and hydronephrosis can occur.
• Liposarcoma and fibrosarcoma are common.
• Radical surgery should be attempted and it is the only hope of cure. (Many cases may require debulking and follow-up with radiotherapy and chemotherapy.)

3. Carcinoma Body of Pancreas

• Cystadenocarcinoma of the pancreas can attain a huge size. Otherwise, it is uncommon to get a large nodular pancreatic mass. However, carcinoma pancreas presenting as a palpable nodular mass indicates nonresectability. The presence of pulsations over the mass (transmitted) clinches the diagnosis.
• Men in the 6th decade are usually affected.
• Severe backache, loss of weight, and recent development of diabetes suggest pancreatic pathology.
• Jaundice does not occur unless and until liver secondaries develop.
• It has all the features of retroperitoneal mass.
• These cases are advanced with ascites, rectovesical deposits, etc.

4. Carcinoma Transverse Colon

• Elderly patients present with constipation and bleeding per rectum.
• A firm to hard nodular mass occupying the umbilical region may be found.
• It may have vertical mobility and being intraabdominal, it falls forward.
• Caecum may be distended. Right to left peristalsis may be visible.

5. Tuberculous Abdomen

• The mass can be rolled up omentum, with lymph nodes and coils of intestines which are matted.
• This is common in children and also occurs in young adults in India.
• History of evening rise in temperature, loss of weight, loss of appetite, emaciation and improper digestion gives the clue to the diagnosis.
• Ascites are present in almost all cases.
• Features of subacute intestinal obstruction can also be present.

The Cystic Mass In The Abdomen

• Intra-abdominal cystic swellings are interesting swellings. They occur in young children, adults, and middle-aged persons.
• There are many cases of cystic swellings which have given a surprise at laparotomy (notoriously so in females).
• In children, cysts have confused many competent paediatricians!! Being intra-abdominal cysts, it is not possible to elicit fluctuation and very often they are firm due to increased tension.

1. Pseudocyst of Pancreas

• Tensely cystic upper abdominal mass may feel firm and tender and does not move with respiration.
• Getting above the swelling is possible. Transmitted pulsations of the aorta can be felt over the mass which disappears on the knee-elbow position.
• A history of acute pancreatitis or blunt injury abdomen gives the clue to the diagnosis

2. Hydatid Cyst of Liver

This swelling is of long duration, is symptomless or with dull pain in the upper abdomen. The cyst is spherical with a smooth surface, and rounded borders and feels firm. Since it is a mass arising from the liver, it moves with respiration and getting above the swelling is not possible. Classical hydatid thrill, mentioned in the books, is rarely appreciated. A simple cyst of the liver can also present as a cystic mass.

3. Mesenteric Cyst

These are congenital cysts, heterogeneous or chylolymphatic, manifest in young children or during adolescence. Typically, the cyst is located in the umbilical region which moves at right angles to the direction of mesentery.

Types of Mesenteric Cysts

1. A chylolymphatic cyst is a lymphatic cyst arising from the mesentery of the ileum. It is a thin-walled cyst with clear fluid or chyle. It has a separate blood supply. Hence, enucleation is the treatment without sacrificing the bowel.
2. An erogenous cyst is a duplication cyst from the intestine or due to the diverticulum of the mesenteric border of the intestine. It is thick-walled and contains mucus. This cyst is treated by excision of the cyst with the bowel segment because both share the same blood supply.

 

Mesenteric Cyst—Types

• Chylolymphatic cyst
• Enterogenous cyst
• Urogenital remnant
• Teratomatous dermoid cyst

Mesenteric Cyst Tillaux’s triad

1. Fluctuant swelling near the umbilicus.
2. Movement perpendicular to the line of mesentery.
3. It is dull surrounded by a zone of resonance and traversed by a band of resonance.

Mesenteric Cyst Complications

• Torsion of the cyst results in acute abdominal pain.
• Rupture of the cyst due to trauma.
• Haemorrhage into the cyst.

4. Hydronephrosis

• Large hydronephrosis can attain a huge size without producing any symptoms. The bulk of the swelling is confined to one side of the abdomen, with a prominent bulge in the loin.
• It is difficult to elicit fluctuation in a tensely cystic intra-abdominal mass. Bimanual palpation and palatability give the clue to the diagnosis. One of the large cysts of the polycystic kidney can present as a large renal cyst.

5. Ovarian Cyst

• It is a freely mobile, firm or soft mass in any quadrant of the abdomen. Such ovarian cysts, once they come out of the pelvis will have free mobility.
• On pushing the mass upwards there will be traction on the pedicle, which may result in pain.
• In any female patient who presents with lower abdominal mass, ovarian mass has to be considered first, and only then consider other possibilities.

6. Retroperitoneal Lymphatic Cyst

• A retroperitoneal cyst is one of the most common lymphatic cysts, which grows slowly to attain a large size.
• Typically it is painless, seen in young patients and is tensely cystiThe bowel loop may be felt over the mass (retroperitoneal mass), or bowel loops may be pushed to the side.

7. Encysted Ascites

This consists of ascitic fluid loculated by many loops of the intestine along with the omentum. Loss of weight, fever, anorexia, and emaciation are the other features.

8. Abdominal Aortic Aneurysm (AAA)

• The majority of cases are due to atherosclerosis and most of the aortic aneurysms are infrarenal. Hence, they present with a swelling in the umbilical region or epigastric region and are associated with backache
• Often they contain clotted blooHence, they feel firm, not compressible, fixed and tender.
• A characteristic feature of an abdominal aortic aneurysm is expansile pulsation. This can be appreciated by palpating the swelling gently all around the knee-elbow position, the pulsations do not disappear. (Transmitted pulsations disappear in the knee-elbow position.)
• The femoral pulses may be normal unless there is thrombosis or rupture of the aneurysm, giving rise to features of acute ischaemia.
• Pressure effects such as venous oedema due to pressure on the inferior vena cava or erosion of vertebrae may be found.
• Ultrasound to confirm the aneurysm and also to rule out suprarenal aneurysm.
• It is treated by repair of the aneurysm, by incising the aneurysm and suturing a dacron graft end to end, inside the aneurysmal sac.

Aortic Aneurysm

• Elderly males >60
• Hypertensive
• Expansile pulsation +
• Anterior rupture: 20%—haemoperitoneum
• Posterior rupture: 80%—retroperitoneal haematoma
• >6 cm size—dangerous

9. Rare Cystic Swellings in the Abdomen

• Omental cyst: This is usually a lymphatic cyst which occurs in children and can attain a huge size. Sudden enlargement indicates haemorrhage. Excision is easy.
• A large mucocele of the gallbladder can present as a tense cystic, slightly tender mass in the upper abdomen.

Mass In The Epigastrium

• Mass in the epigastrium is one of the common long cases kept in the examination. Students should consider mass arising from the liver and stomach first. Other possibilities must be considered later because common cases are common.

1. Mass Arising In The Abdominal Wall

• First do the head-raising test. If the mass becomes more prominent, it is extraperitoneal (abdominal wall).
• Lipoma, neurofibroma or desmoid tumour arising from the rectus sheath can present as a mass in the epigastrium.
• Also, note epigastric hernia occurs in this region. It is a hernia, not a mass. Any hard subcutaneous swelling in the abdominal wall of recent origin can be a metastasis.

2. Intraperitoneal Mass

1. Mass Arising from the Liver

1. Hepatoma: Liver is enlarged, hard, irregular, and nontender. However, rapidly growing hepatomas are tender, and firm and even a bruit is heard over the swelling. Rapid deterioration of health in a cirrhotic patient is usually due to the development of a hepatoma.
2. Secondaries in the liver: Usually both lobes are enlarged, and have nodular surfaces without a bruit. Jaundice is a late feature in the secondaries of the liver. The primary may be obvious as a colonic mass, a stomach mass a testicular tumour, etc.
3. Hydatid cyst: It is a benign swelling. History of contact with a dog is usually present. Epigastric swelling is due to an enlarged liver which is smooth or irregular, nontender with rounded borders. Classical hydatid fremitus and thrill are rarely elicited. The general health of the patient is usually good.
4. Simple cyst: It is not a clinical diagnosis but is mentioned here only for discussion. It is a serous cyst. A single big cyst can also be a part of the polycystic disease of the liver.

2. Mass Arising from the Stomach

• For all practical purposes, the only mass arising from the stomach in the epigastrium is carcinoma stomach.
• It is hard, irregular and moves with respiration. Usually, the patient is a male with a loss of appetite and weight.
• Vomiting is a feature. If there is a growth in the pyloric antrum, visible gastric peristalsis can be seen in the epigastrium.
• (Students are hereby requested not to offer lymphoma of the stomach or GIST of the stomach as a clinical diagnosis unless asked for by the examiner, for a differential diagnosis.)

3. Omental Mass

• Omentum gets involved in tuberculosis as a firm, nodular mass or in secondaries from intraabdominal malignancies as a hard, nodular mass. Classically it moves with respiration.
• Rarely, the omental cyst can present as a tense cystic mass in the epigastrium.

Retroperitoneal Mass

1. Pseudopancreatic cyst: It forms a tense cystic mass, felt as a firm mass in the epigastrium. Its upper border can be made out.
   1. It does not usually move with respiration. It has a smooth surface and round borders. A history of acute pancreatitis or blunt injury abdomen is usually present.
   2. Pulsations over the mass (transmitted) suggest that it is a mass close to the aorta such a case, it is a pseudocyst. A gurgle heard anteriorly suggests a distended stomach.
2. Cystadenoma: Cystadenomas of the pancreas are benign and can attain huge sizes. It can present as a mass in the epigastrium, left hypochondrium or umbilical region. They exhibit what is described as ‘tree top mobility’.
3. The carcinoma body of the pancreas can present as a mass in the lower part of the epigastrium or upper umbilical region. The mass is hard, irregular, fixed and does not move with respiration. The presence of severe backache and loss of weight are important features.
4. Abdominal aortic aneurysm (AAA): An elderly patient, usually a hypertensive presents with features of abdominal pain, swelling or features of ischaemia of the lower limOn examination, tender swelling in the epigastrium with a characteristic expansile pulsation is present. Knee-elbow test will help differentiate it from transmitted pulsations. The presence of a bruit and weak or absent lower limb pulses (due to thrombus) also helps in establishing the diagnosis.
5. Lymph node mass.

Mass In The Right Hypochondrium

1. Parietal: On the head-raising test, the lump becomes more prominent.
   1. Lipoma, neurofibroma: They can be part of multiple lipomatosis or multiple neurofibromatosis. If pain and pigmentation are present, it is neurofibroma.
   2. A hard nodule in the parietal wall can be due to
      1. Secondary deposit in the skin/subcutaneous tissue especially when skin is infiltrated and ulcerated. Common primaries are malignant melanoma, bronchogenic carcinoma, and hepatoma.
      2. Non-Hodgkin’s lymphoma: ‘T’ cell type.
      3. Cold abscess: Spine tenderness with or without a history of tuberculosis gives the clue to the diagnosis.
2. Intra-abdominal swellings: On the head-raising test, the lump becomes less prominent.
   1. Liver: Only chronic masses are discussed.
   2. Secondaries in liver
      • The entire liver is enlarged (both lobes)
      • Nodular surface
      • Sharp border
      • Hard in consistency

Anatomic Features of Liver Mass

• Location: Hypochondrium (right and left) and epigastrium
• Moves with respiration
• Finger—insinuation between costal margin and mass is not possible
• No intrinsic mobility and dullness
• Dull note over the liver which will continue with the mass
• Rare umbilication signs, evidence of primary, emaciated patient, poor health, loss of appetite and weight are other features.

Mass In The Right Hypochondrium Hepatoma

• One lobe is enlarged
• Firm to hard, irregular
• Very tender liver
• Bruit/thrill may be present

Tender Liver Mass

• Hepatoma
• Amoebic liver abscess
• Suppurative pylephlebitis
• Congestive cardiac failure
• Infected hydatid cyst
• Evidence of chronic liver disease such as serum hepatitis or cirrhosis is usually present.

Polycystic disease of the liver

• Both lobes are enlarged
• Nodular
• Nontender
• Round borders
• General health is good
• The patient would have presented to the hospital with pain due to a haemorrhage in a cyst.

Mass In The Right Hypochondrium Hydatid cyst

• One or both lobes are enlarged
• Smooth or nodular surface
• Round borders, non-tender
• The general condition of the patient is good
• Hydatid thrill—rare ‘physical sign’ may be present.

Mass In The Right Hypochondrium Cirrhosis of liver

• The liver may be enlarged: Firm and irregular in pre-cirrhotic cases. Splenomegaly and ascites will help in the diagnosis.
• Other features of liver cell failure such as gynecomastia, spider naevi, and palmar erythema may be present.

Mass In The Right Hypochondrium Lymphoma

• Liver is palpable, one or two finger-breadths, firm or hard, smooth or irregular, non-tender.
• Splenomegaly and lymphadenopathy will help in the diagnosis.

Congenital Riedel’s lobe:

It is a tongue-shaped projection from the inferior border of the liver. It is on the right side and can be mistaken for gallbladder.

Gallbladder mass

Causes of gallbladder enlargement

• Back pressure: Distal obstruction periampullary carcinoma such as gallbladder is firm, smooth and associated with jaundice.
• Carcinoma gallbladder: Hard, irregular, fixed
• Acute cholecystitis: Tender, vague, well-defined mass

Clinical Features of a Gallbladder Mass

1. It is oval, e.g. egg-shaped swelling
2. It is tense. Hence, feels more firm in consistency
3. Moves freely up and down with respiration—better seen in thin patients
4. May have slight side-to-side mobility
5. It is felt slightly posterior to the (step deep) inferior border of the liver

Mucocele: Nontender, palpable gallbladder without jaundice

Empyema: Very tender, gallbladder mass

Colonic mass Carcinoma hepatic flexure

• Firm to hard irregular mass
• Restricted mobility
• Moves with respiration because of its contact with the liver
• Resonant or impaired resonant note on percussion (liver is dull on percussion
• Caecum may be distended, if there is obstruction.

Large ileocaecal tuberculosis with pulled-up caecum may also be palpable. Such masses may be bimanually palpable but not ballotable.

Gallbladder mass Renal mss

• Importantly renal mass is palpable mainly in the lumbar region, loin and in the right hypochondrium.
• Carcinoma kidney is hard and irregular
• The upper border is usually not palpable—it is under cover of the 12th rib.
• Hydronephrotic kidney will be firm and smooth

Suprarenal mass

• Clinically they have all the features of a renal mass
• Hence, the symptoms of the patient may have to be correlated few examples are given here:
  • Cushing’s syndrome
  • Phaeochromocytoma

Mass In The Right Lumbar Region

1. Renal mass:

• Renal masses are the most common masses in the lumbar region followed by colonic masses.
• The kidney is present in the loin and it is a posterior structure. Hence, in the majority of the cases, enlargement is more obvious posteriorly. However, uniform enlargement causes the kidney to enlarge anteriorly thus making it bimanually palpable.
• One characteristic feature of renal mass is palatability. Kidney ballots because it has a pedicle and a cushion of the perirenal pad of fat surrounding it.
• Ballotability is demonstrated by the following method
• One hand is kept posteriorly close to the abdominal wall and the other hand anteriorly.
  • A push (ballot means to toss) is given with posterior hand mass tosses and touches the hand, anteriorly placed and goes back. Thus, the following features of a kidney help to say that mass is arising from the kidney.
  • The kidney is present in the lumbar region and it has a reniform shape.
  • It enlarges in a superoinferior direction.
  • It moves with respiration because it is enclosed by the fascia of Gerota which blends with the diaphragm above.
  • It is bimanually palpable and ballotable.
• It is possible to insinuate the fingers between the upper border of the mass and the costal margin.
  • Normal resonant note posteriorly in the loin (colonic) gets obliterated because as the kidney enlarges, it displaces the colon.
• CECT scan is the most common useful investigation to differentiate renal masses.
• The most common renal masses which are palpable in the lumbar region—renal cell carcinoma, polycystic disease and hydronephrosis have been compared in Various causes of hydronephrosis have been given

2. Liver mass:

A large liver mass is easily palpable in the lumbar region. In these cases, you have to present the case as a mass is felt in the right hypochondrium and it extends into the lumbar region. Once you confirm it is the liver, common differential diagnoses include hepatoma, secondaries in the liver, hydatid disease of the liver, etc.

3. Gallbladder mass:

• A large gallbladder mass is palpable in the lumbar region but it starts from the right hypochondrium, The Shape is oval with a smooth surface and tense The usual cause is mucocele.
• Mucocele of the gallbladder is due to a stone blocking the cystic duct and causing massive enlargement of the gallbladder. These patients do not have jaundice. Other causes of enlargement.

4. Ascending colonic mass

Ileocaecal tuberculosis is felt as an irregular or nodular firm mass in the right iliac fossa and in the lumbar region.

The mass is due to thickened caecum and ascending colon. The caecum is higher in position because it is pulled up.

Younger age of the patient, fever, weight loss, loose stools and colicky abdominal pain are the symptoms. (More details under mass in the right iliac fossa).

Carcinoma ascending colon: Typically, a patient is around 50–60 years of age and presents with a change in bowel habits—mucus in the stools and bleeding per rectum.

• Anaemia, loss of weight and weakness are the features. On examination, the mass is palpable in the lumbar region which is firm to hard, irregular with restricted mobility.
• Gurgling is elicited due to the presence of air in the lumen, thus it differentiates from solid organ enlargement.
• Large tumours can be bimanually palpable but they are not ballotable. A colonoscopy to confirm the diagnosis followed by an ultrasound and CT scan to know the metastasis and resectability are investigations.
• Right radical hemicolectomy or extended hemicolectomy depends upon whether the hepatic flexure is involved or not is the treatment of choice.

GIST:

• Patients with gastrointestinal stromal tumours are between 20 and 50 years of age. These tumours attain a large size.
• They grow outside the lumen and hence do not produce obstruction. However, a mucosal ulceration results in bleeding. The stomach is the most common site of GIST.
• GIST arising from intestines can present in the lumbar region. This should be the exclusion diagnosis.

If you suspect a bowel mass think of colonic malignancy first, followed by tuberculosis second and chronic intussusception third all 3 are ruled out, if features of GIST are present, then offer the diagnosis of GIST.

Chronic intussusception:

• It is usually a firm gurgling mass with regular borders which may contract during palpation. Recurrent or intermittent abdominal pain for one or two years may be present. Chronic intussusception is non tender.
• When the intussusception reduces, all symptoms will disappear. Percussion will reveal a resonant note.
• Most of the patients are young. If intussusception is the diagnosis in the elderly, it is usually ileocolic or colocolic and invariably a colonic malignancy is the cause. These intussusceptions are called secondary intussusceptions.
• The common causes of secondary intussusception or chronic intussusception are polyps, purpura, submucosal lipoma, Meckel’s diverticulum, carcinoma, carcinoid, ultrasound followed by CECT scan is done to confirm the diagnosis followed by resection of the bowel and anastomosis.

5. Retroperitoneal mass:

• Typically retroperitoneal masses are liposarcomas. They occur in young patients. They can attain huge size before they become clinically palpable. They present with painless, progressive, massive enlargement of the abdomen.
• Compression on the iliac veins will result in unilateral limb oedemInferior vena cava obstruction may cause bilateral limb oedema and dilated veins in the flank (inguinoaxillary veins).
• Examination will reveal a large, firm, irregular mass with all borders felt and with restricted mobility. On percussion, a resonant note is felt because of the intestines over the surface of the mass.
• Liposarcoma is the commonest retroperitoneal sarcomas followed by fibrosarcoma or epithelioid sarcomas.
• CT scan is done to locate the tumour to find out the vascular invasions and to find out the infiltration of the surrounding structures. Resection of the tumour is the best form of treatment. All other modalities such as chemotherapy and radiotherapy are palliative.

Abdominal Mass Multiple Choice Questions

Question 1. The most diagnostic sign of a renal mass is:

1. Moves with respiration
2. The upper pole cannot be felt
3. It enlarges downwards
4. Ballotability

Answer: 4. Ballotability

Question 2. Which one of the following lower horizontal lines divides the abdomen into regions?

1. Transpyloric line
2. Transcolic line
3. Transtubercular line
4. Transanterior superior iliac spine line

Answer: 3. Transtubercular line

Question 3. Which of the following masses does not move with respiration?

1. Kidney
2. Hepatic flexure
3. Tail of the pancreas
4. Para-aortic lymph node mass

Answer: 2. Hepatic flexure

Question 4. Notch is a diagnostic sign of which mass?

1. Spleen
2. Liver
3. Kidney
4. Adrenal gland

Answer: 1. Spleen

Question 5. Which of the following does not have intrinsic mobility?

1. Fibroadenoma breast
2. Ovarian cyst
3. Mesenteric cyst
4. Multinodular goitre

Answer: 4. Multinodular goitre

Question 6. The following is true for renal masses except:

1. It is manually palpable
2. It is ballotable
3. It does not move with respiration
4. The upper border is usually not felt

Answer: 3. It does not move with respiration

Question 7. Blumer’s shelf refers to:

1. Rectouterine pouch
2. Rectovesical pouch
3. Rectosacral pouch
4. Rectoprostatic pouch

Answer: 2. Rectovesical pouch

Question 8. Following tumours can occur in the abdominal wall except:

1. Desmoid tumour
2. Endometriosis
3. Dermoid tumour
4. Fibromatosis

Answer: 3. Dermoid tumour

Question 9. Following appendicectomy, after 2 months, if a woody indurated mass develops in the right iliac fossa with sinuses, what is the diagnosis?

1. Tuberculosis
2. Crohn’s disease
3. Amoeboma
4. Actinomycosis

Answer: 2. Crohn’s disease

Question 10. Acute intussusception mass has the following features:

1. Mass is tender
2. Mass is felt in the umbilical region
3. It is a sausage-shaped mass
4. In the right iliac fossa caecum gurgles

Answer: 1. Mass is tender

Question 11. Which of the following masses does not have cross fluctuation?

1. Iliopsoas abscess
2. Plunging ranula
3. Collar stud abscess
4. Branchial cyst

Answer: 4. Branchial cyst

Question 12. The following is true for retroperitoneal sarcoma except:

1. Common in young patients
2. Mass does not move with respiration
3. It can attain a hard and large mass
4. Free fluid is usually present in the abdomen

Answer: 4. Free fluid is usually present in the abdomen

Question 13. The diagnostic feature of a mesenteric cyst is:

1. It is present in the umbilical region
2. It is dull to percuss
3. It falls forward
4. Moves at a right angle to the direction of the mesentery

Answer: 4. Moves at right angle to the direction of the mesentery

Question 14. Which of the following masses is nontender?

1. Hepatoma
2. Appendicular mass
3. Carcinoma stomach
4. Cholecystitis

Answer: 3. Carcinoma stomach

Question 15. Murphy’s triad of symptoms includes the following:

1. Pain
2. Vomiting
3. Fever
4. Jaundice

Answer: 4. Jaundice