Abdominal Masses
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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Presentation
Abdominal masses are usually detected on physical examination rather than presented by the patient. Any patient with an unexplained abdominal mass should be referred for urgent specialist assessment[1].
Examination
- Examine supraclavicular and inguinal nodes.
- Inspection - scars (especially around the umbilicus for laparoscopy scars), distension, prominent veins, local swelling, pulsation, visible peristalsis, skin lesions, asymmetrical movement at eye level. Exclude lesions of the abdominal wall: the patient raises their head (no good for the lateral abdomen); the patient does straight leg-raising (Carnett's method), 'blowing test' (Valsalva's test); the patient strains as if toileting (Kamath's test)[2].
- Palpation - use warm hands, and examine the tender areas last. Light palpation, then deep. Check for guarding, rigidity and rebound tenderness. Determine for any mass: site, tenderness, size and shape, surface (irregular or smooth), edge (regular or irregular), consistency (soft or hard), mobility, whether pulsatile or ballotable.
Causes of Abdominal Mass by Location | ||
|---|---|---|
Right upper quadrant
| Epigastric
| Left upper quadrant
|
Right flank
| Periumbilical
| Left flank
|
Right iliac fossa
| Suprapubic
| Left iliac fossa
|
| Pelvis (should not be able to palpate below mass)
| ||
Editor's note
Dr Sarah Jarvis, 11th February 2021
In September 2020 and in January 2021, the National Institute for Health and Care Excellence (NICE) published its updated guidance on suspected cancer recognition and referral[1].
The guidance recommends that in women, doctors should make an urgent referral to a gynaecological cancer service if physical examination identifies ascites and/or a pelvic or abdominal mass (which is not obviously uterine fibroids).
In addition, if ultrasound is ordered, the guidance confirms that if the ultrasound suggests ovarian cancer, an urgent referral should be made to a gynaecological cancer service.
Investigations
Investigations will depend on the site and likely clinical diagnosis The following may be helpful:
- Early ultrasound or CT scan.
- Hollow organs may require the use of a contrast medium (eg, barium enema, gastrointestinal series, intravenous pyelogram).
- FBC with film, ESR, U&Es.
- LFTs.
- CXR and abdominal X-ray.
- Ultrasound or CT-guided fine-needle biopsy.
- Mantoux test.
- Paracentesis with fluid examination if ascites is present.
- Laparoscopy or laparotomy may ultimately be necessary to achieve a diagnosis.
Further reading and references
Suspected cancer: recognition and referral; NICE guideline (2015 - last updated December 2021)
Carnett's test; whonamedit.com