أورام المعدة والجهاز الهضمى- لغة انجليزية-كتبته بنفسى-abdominal swellings

[mohamed_ameer]

أورام المعدة والجهاز الهضمى- لغة انجليزية-كتبته بنفسى-ABDOMINAL SWELLINGS

parietal swellings

swellings of the anterior abdominal wall are readily differentiated from intra-abdominal swellings by three signs:-

a- relation to the costal margin:- if the swelling extends over the costal margin, it is obviously extra-abdominal where as intra- abdominal swellings disappear beneath the margin.

b) behaviour on contraction of the abdominal muscles :- intra-abdominal swellings become less visible or disappear on contraction of the muscles where as parietal swellings become more prominent. c) movement on respiration :- swellings which move freely up and down with deep respiration are obviously intra-abdominal while parietal swellings show merely anteroposterior movement with the anterior abdominal wall.

besides cysts and tumours of the skin and subcutaneous tissues, as may occur in other situations, the special parietal swellings of the abdomen are the following :-

1- cold abscess may arise from caries of the ribs or spine. it gives rise to a fluctuating swelling in the hypochondrium or lion. examinations may reveal irregularity of the affected rib or deformity of the spine, x-ray examination confirms the diagnosis.

2- pyogenic abscess may occur in the rectus sheath or abdominal wall as parietal abscess or may result from burrowing of an intra-abdominal abscess, hepatic, subphrenic, perigastric or appendicular abscesses.

3-haematoma of the rectus sheath may result from rupture of the inferior epigastric vessels or the rectus muscle it self. it may result from trauma, about of coughing or sneezing or the convulsions of tetanus and strychnine poisoing. the haematoma forms a tender lump in the rectus sheath associated with severe pain and sometimes with eccchymosis and purple discolouration of the overlying skin. the swelling becomes more prominent and fixed on contraction of the abdominal muscles.

4- Hernias occur at the hernial sites umbilicus, linea alba ( epigastric hernia), inguinal canal (inguinal hernias), linea semilunaris (spiegelian hernia), lumbar triangle (lumbar hernia) or laparotomy scars (incisional hernia). the hernia forms a soft reducible swelling with an expansile impulse on coughing.

5- desmoid tumour is fibrosarcoma of low-grade malignancy septa of the muscle itself. it occurs most often in multiparous women either spontaneously or after an abdominal operation. it forms a hard nodular mass which moves slightly from side to side but becomes fixed on contraction of the rectus. it grows slowly but eventually it infiltrates the peritoneum, subcutaneous tissues and even the pubic bones. it tends to recur after operation and the recurrent growth becomes more malignant than the original one.


swellings of the right hypochonodrium

1- swelling of the liver :- enlargement of the liver is best determined by percussing its upper border and palpating its lower edge. in order not to miss a hugely enlarged liver, the palpation is started low down in the right iliac fossa and the hand is moved upwards little by little until the lower edge is felt. the right hand is applied to the abdomen just lateral to the linea semilunaris with index finger at right angles to the edge of the rectus muscle. the patient is instructed to take deep respirations while the hand is dipped deeply backwards and upwards towards the end of respiration to meet the descending edge of the liver.

when examining a hepatic swelling , record the amount of enlargement in finger-breadths below the costal margin and note the character of the edge (sharp or rounded) and surface ( smooth or nodular), the consistency ( soft, firm, hard or heterogeneous), the presence of tenderness and the degree of movement on respiration.


2- gall-bladder swelling : an enlarged gall- bladder feels as a rounded or ovoid swelling close behind the anterior abdominal wall. it has a rounded lower end with a smooth surface but no upper margin. it moves with respiration and can be moved sideways but can not be held down or pushed into the lion like a kidney swelling. it is usually tender and has a tense cystic consistency.


3- subphrenic abscess :- there is often a recent history of operation or suppurative lesion in the abdomen perforated peptic ulcer cholecystitis, liver abscess or appendicitis. the patient is toxic with hectic fever, rigor, excessive sweating, rapid pulse, wasting and anorexia. pain may be entirely absent but there is often epigastric discomfort or reffered pain in the right shoulder. palpation reveals tenderness over the lower ribs or immediately below the costal margin and palpable oedmatous swelling may be present. percussion often reveals dullness over the base of the lung (pleural effusion or empyema) and if the abscess contains gas, four percussion zones may be elicited:- normal lung resonance, dullness of effusion, resonance of gas in the abscess and liver dullness. radiography shows an elevated fixed diaphragm (tented diaphragm) with obliteration of the costophrenic sinus and gas may be visualized under the diaphragm if the abscess is due to perforation of a hollow viscus or to anaerobic infection.


4- carcinoma of the hepatic flexure of the colon:- the swelling is firm and irregular and moves very slightly with respiration. the patient is usually a male over 40 with a history of alternating attacks of diarrhoea and constipation. the barium meal and enema show an irregular filling defect which clinches the diagnosis.

5- renal swellings:- a kidney swelling has the following characters :- a ) it has a reinform shape with a smooth or lobulated surface and rounded edge. b) it projects vertically downwards towards the illiac fossa and never crosses the middle line. c) it fills the loin and if floating it can be pushed into it. d)it moves freely with respiration and as it comes down on deep inspiration, it can be held down bimanually. e) it lies insinuated between the swelling and the costal margin. f) if grasped between the two hands it causes a sickening sensation. g) it can be balloted between the two hands unless it is very large. h) the renal angle is dull on percussion and a band of resonance can often be detected in front of the swelling due to gas in the colon.

the causes of renal enlargement are numerous but the commonest in this country are hydronephrosis and pyonephrosis.
less common swellings are polycystic kidney, hypernephroma and Wilm's tumour. the association of a renal swelling with total haematuria or varicocele is very suspicious of malignancy.

6) suprarenal swellings are commonest in children. they are deeply situated and difficult to diagnose unless associated with endocrine symptoms. virilism and precocious puberty. intra-venous pyelography, retropneumo-peritoneum and aortography are very helpful investigations.


7) retroperitoneal tumours :- retroperitoneal sarcoma often forms a large firm nodular mass fixed to the posterior abdominal wall and showing no movemtnt on respiration. later on, pressure on the inferior vena cava leads to oedema of the lower limbs and involvement of the peritoneum produces malignant ascites



swellings of the epigastrium

the most common parietal swelling is epigastric hernia (fatty hernia of the linea alba). intra-abdominal swellings may arise in the liver, subphrenic space, stomach, transverse colon, omentum, pancreas, aorta, lymph nodes or retroperitoneal tissues.

1- gastric swellings are either due to pyloric obstruction or to tumours of the stomach

a)congenital hypertrophic pyloric stenosis affects infants between the third and fifth weeks after birth. the cardinal symptoms are projectile vomitting (never bile-stained) and constipation. examination reveals visible peristalsis and a " pyloric tumour" is often palpable as a firm ovoid swelling about the size and shape of an olive.

b) acquired pyloric obstruction is usullay a complication of chronic duodenal ulcer. the dilated stomach forms a resonant swelling with visible peristalsis passing from the left to the right.

c) carcinoma of the stomach is the commonest gastric tumour. sarcoma and benign neoplasms are rare.

2- omental swelling :- in tuberculous peritonitis, the greater omentum is often thickened and rolled up to form a transverse sausage-shaped mass in the epigastrium.

3- pancreatic swellings :- cysts are the commonest palpable swellings. true cysts are rare but false cysts are common after trauma or pancreatitis. the swelling is usually rounded and placed centrally above the umbilicus and is often so tense that fluctuation can not be elicited. transmitted pulsation from the aorta may be present but the pulsations disappear in the knee elbow position.. barium meal examination shows that the swelling lies behind the stomach and this is best seen in the lateral view.

4- aneurysm of the upper part of the abdominal aorta is rare. the swelling exhibits true expansile pulsation which does not disappear with change of posture


5- enlarged lymph nodes may be due to tuberculosis, primary lymphomas or secondary deposits from the abdominal viscera or testis.



swellings of the left hypochondrium

parietal swellings are the same as on the right side. intra-abdominal swellings occur in connection with the spleen, liver, stomach, splenic flexure of the colon, tail of the pancreas, left subphrenic space, left kidney, left suprarenal gland and retroperitoneal tissues in this area. splenic and renal swellings are by far the commonest and most important. renal swellings have been discussed under swellings of the right hypochondrium


1- splenomegaly :- an enlarged spleen is readily recognized by the following signs :-

a) the spleen enlarges towards the umbilicus. downwards , fowards and medially, whereas the kidney projects directly downwards towards the iliac fossa.

b) the swelling is usually smooth, firm and uniform with a sharp anterior border often showing a distinct notch towards the lower pole.

c) the swelling is more mobile and moves more freely with respiration than does a renal swelling.

d) the spleen hugs the anterior abdominal wall so that is palpated more easily from the anterior spect and the fingers can not be insinuated between the swelling and the costal margin.

e) the splenic swelling is uniformly dull on percussion whereas a renal swelling often shows a band of colonic resonance across its anterior surface.

f) the renal angle is empty and resonant.

g) the swelling can not be balloted between the two hands.



once the swelling is diagnosed as an enlarged spleen, the cause of the enlargement should be determines. .. the patient is usually a young or middle-aged farmer with a history of bilharziasis,,urinary, intestinal or both.... clinically , signs of anaemia and mulnutrition are present and abdominal examination reveals a cirrhotic liver often associated with divarication of the recti, fatty hernias of the linea alba or dilated paraumbilical veins (caput meduse). in late cases, haematemesis, ascites and oedema of the lower limbs may develop... the diagnosis is confirmed by urine, stool and blood examination, liver function tests, barium swallow and splenoportography.


leukoemia is the next important cause of splenomegaly ... it may be acute, myeloid or lymphatic.. besides the splenic enlargement, there is generalized lymphadenopathy and hepatomegaly and there may be bone pains and spontaneous haemorrhages .. the blood picture and sternal puncture are diagnostic and should be carried out in every case of splenomegaly with generalized enlargement of the lymph nodes.

all other causes of splenomegaly are rare... they include malaria, kala-azar, hodgkin's disease, Gaucher's disease, acholuric jaundice, thrombocytopenic purpura, amyloid disease, abscess, cyst and tumour.


2- liver swelling :- a tumour of the left lobe of the liver rarely forms a swelling in the left hypochondrium. in these cases , the swelling encroaches on the epigastrium and is continous with the liver which is often enlarged and palpable.

3- carcinoma of the splenic flexure :- the tumour rarely reaches such a size to be palpable as a mass in the left hypochondrium ... in these cases, obstructive symptoms are usually present and a barium meal or enema establishes the diagnosis.


4- gastric tumours, particularly subserous myoma, may appear as a swelling in the left hypochondrium. .. the diagnosis is confirmed by barium meal examination.



swellings of the right and left lumbar regions

the special parietal swellings and lumbar abscess and lumbar hernia. both conditions give rise to a soft swelling with an expansile impulse on coughing. they are differentiated from each other by testing for reducibility and by percussion. the hernia is completely reducible and tympanitic whereas the abscess is merely compressible and dull on percussion. in cold abscess, evidence of spinal caries(deformity, tenderness, rigidity and radiographic changes) confirms the diagnosis.

intra-abdominal swellings arise from the colon or kidney or extend from neighbouring regions.


1- right side:- the swelling may develop in connection with the appendix, caecum, ascending colon, right kidney, gall bladder or liver.

2- left side :- the descending colon, left kidney or spleen may be responsible for the swelling.



swellings of the umbilical region

the special parietal swellings are those of the umbilicus (hernia, polyp or malignant nodules) and rectus cheath (haematoma, abscess and desmoid tumour). intra-abdominal swellings may develop in connection with the stomach, transverse colon, omentum, pancreas, small intestine, mesentery, mesenteric lymph nodes, aorta or retroperitoneal tissues. ..in addition, swellings from neighbouring areas may encroach on this region, splenic, uterine and ovarian swellings... the most important swellings are those of the small intestine, mesentery and retroperitoneum.


1- swellings of the small intestine are chiefly neoplastic , lipoma , myoma and carcinoma.

2- tuberculous mesenteric lymphadentitis (tabes mesenterica) is commonest in young children... the chief symptoms are abdominal pain and alternating attacks of diarrhoea and constipation togather with general symptoms of tuberculous toxaemia (anorexia, pallor, night sweats, evening pyrexia and progressive wasting ). the affected lymph nodes may be palpable as rounded, tender firm masses and local cold abscess may develop just to the right of the umbilicus.


3- mesenteric cyst usually occurs in children as a painless abdominal swelling.. the sighns are well-summarized by Tillaux's triad:- a) a rounded smooth cystic swelling in the centre of the abdomen , b) moving freely in a plane at right angles to the line of attachment of the mesentery

c) showing a zone of resonance around and a belt of resonance over the swelling.


4) retroperitoneal tumours are mainly due to malignant lymph nodes or soft tissues tumours. lipoma and sarcoma.



.swellings of the right iliac fossa

there are no special parietal swellings except those extending from the inguinal region... intra-abdominal swellings usually arise in connection with the appendix, illeocaecal region, right kidney, right testis, iliac lymph glands, illiac blood vessels, illiopsoas muscle, psoas sheath and illiac bone.

1- Appendicular mass is the commonest swelling in the right iliac fossa.. it usually appears on the third day after the commencement of the attack... it forms a tender fixed lump with some rigidity of the abdominal wall but in a few days the rigidity passes off and mass becomes more circumscribed and slightly movable... in neglected cases, however, suppuration may occur and the abscess may point on the surface, causing inflammatory signs in the abdominal wall.

2- swelling of the iliac bone are most often due to osteomyelitis, osteoclastoma or sarcoma.

3- renal mass :- an ectopic or ptosed kidney may be felt as a tender well-defined swelling in the right iliac fossa.. pyelography confirms the diagnosis....

4- iliac aneurysm is rare but can be readily diagnosed by the expansile pulsation.

5-illeocaecal mass :- a) hyperplastic ileocoecal tuberculosis :- the patient is young and the onset is insidious with vague pain in the right iliac fossa, loss of weight and alternating attacks of constipation and diarrhoea.... examination reveals a firm tender mass, usually dull on percussion and may be fixed or mobile. in late cases, chronic intestinal obstruction develops with colicky abdominal pain, borborygmi, distension and progressive constipation.... barium meal or enema reveals an extensive filling defect with marked stenosis of the caecum and ileal stasis. unlike carcinoma, the caecum is often displaced upwards outside the iliac fossa, the ileocaecal angle is obtuse and because of associated ileal spasm, the barium seems to jump from the ileum to the hepatic flexure. ( stierlin's barium jump sign )


b- actinomycosis is very rare in this country. the patient is usually a young adult male, complains of pain in the right iliac fossa or presents with a discharging sinus after appendicectomy... examination reveals a hard fixed mass in the right iliac fossa with fixed flexion of the hip joint due to involvement of the psoas muscle.... in late cases, the abdominal wall becomes indurated and riddled with discharging sinuses and sulphur granules may be detected in the collected pus.

[mohamed_ameer]

اورام المعدة و الجهاز الهضمى – انجليزى – كتبته بنفسى-abdominal swelling

Swellings of the left iliac fossa

These are the same as on the right side except that the appendix and ileocaecal region should be substituted by the sigmoid colon and the gall-bladder by the spleen…swellings of the sigmoid colon include :-

1- carcinoma :- the tumour is rarely palpable as a hard irregular lump in the left iliac fossa; more often what is felt is the loaded colon proximal to the stenosis… signs and symptoms of intestinal obstruction are present and the diagnosis is confirmed by barium enema and sigmoidoscopy

2- bilharziasis :- the patient is usually young and complains of weakness, indigestion, colics and tenesmus with the passage of blood and mucus in the stools… in advanced cases a hard irregular mass is palpable in the abdomen but unlike cancer, signs of intestinal obstruction are slight or absent…multiple papillomata are usually detected on rectal examination… the diagnosis is confirmed by stool examination, sigmoidoscopy and barium enema

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(bilharzial mass of the sigmoid.. barium enema showing narrowing of the lumen and multiple polypi)

3- diverticulitis :- An acute pericolic mass simulates an appendicular mass on the right side.. in chronic cases, a hard nodular mass may stimulate cancer… a history of recurrent acute attacks and demonstration of multiple diverticula by barium enema are in favour of diverticulitis.