DDx – Abdominal distention
Source: Churchill’s Pocketbook of Differential Diagnosis
Bold: common; Italic: rare
Right Upper Quadrant
Liver. See hepatomegaly, p. 215.
Gall Bladder
- Secondary to carcinoma of the head of the pancreas
- Mucocele
- Empyema
- Carcinoma
Right Colon
- Carcinoma
- Feces
- Diverticular mass
- Cecal volvulus
- Intussusception
Right Kidney
- Carcinoma
- Polycystic kidney
- Hydronephrosis
- Pyonephrosis
- Perinephric abscess
- TB
- Solitary cyst
- Wilms’ tumor (nephroblastoma)
GENERAL INVESTIGATIONS
■ FBC, ESR
Hb anemia, e.g. carcinoma of the colon, hematuria with renal lesions. Hb , e.g. hypernephroma (polycythemia associated with hypernephroma). WCC , e.g. empyema, diverticular mass. ESR , malignancy.
■ U&Es
Vomiting and dehydration, e.g. gall bladder and bowel lesions. Ureteric obstruction with renal lesions leading to uremia.
■ LFTs
Liver lesions. Secondary deposits in liver.
■ MSU
Renal lesions – red blood cells, pus cells, malignant cells. C&S.
■ AXR
Intestinal obstruction due to carcinoma of the large bowel. Gallstones (10% are radio-opaque). Cecal volvulus.
Constipation. Calcification in renal lesions.
■ US
Liver lesions. Gallstones. Mucocele. Empyema. Bile duct dilatation.
SPECIFIC INVESTIGATIONS
■ Barium enema
Carcinoma of the colon. Diverticular disease. Intussusception.
■ Colonoscopy
Carcinoma of the colon. Diverticular disease.
■ CT
Liver lesions. Gall bladder lesions. Renal lesions.
LEFT UPPER QUADRANT
SPleen
See splenomegaly, p. 410.
Stomach
Carcinoma
Gastric distension (acute dilatation, pyloric stenosis)
Pancreas
Pseudocyst
Carcinoma
KidneY
See right upper quadrant, p. 9.
Colon
Carcinoma of the splenic flexure
Feces
Diverticular mass
GENERAL INVESTIGATIONS
■ FBC, ESR
Hb carcinoma. Hb hypernephroma (polycythemia is associated with hypernephroma). WCC diverticular disease, renal infections.
■ U&Es
Vomiting, dehydration (with gastric and colonic lesions). Renal lesions.
■ LFTs
Liver lesions. Secondary deposits in liver.
■ Serum amylase
Acute pancreatitis.
■ US
Splenomegaly. Renal lesions. Paracolic abscess.
SPECIFIC INVESTIGATIONS
■ Blood glucose
May be raised in pancreatic carcinoma.
■ Barium enema
Carcinoma. Diverticular disease.
■ Colonoscopy
Carcinoma. Diverticular disease.
■ Gastroscopy
Carcinoma of the stomach. Pyloric stenosis.
■ CT
Carcinoma of the pancreas. Pancreatic pseudocyst. Liver secondaries. Splenomegaly. Paracolic abscess.
EPIGASTRIUM
AbdominAl wAll
Lipoma
Epigastric hernia
Xiphisternum
Metastatic deposits
Stomach
Congenital hypertrophic pyloric stenosis
Carcinoma
Acute gastric volvulus
Pancreas
See left upper quadrant, p. 11.
TRAnSVeRSe Colon
Carcinoma
Feces
Diverticular mass
liVeR
See hepatomegaly, p. 215.
ReTRoPeRiToneUm
Aortic aneurysm
Lymphadenopathy (lymphoma, secondaries from testicular carcinoma)
omenTUm
Omental secondaries, e.g. stomach and ovary
GENERAL INVESTIGATIONS
■ FBC, ESR
Hb carcinoma of the stomach, carcinoma of the colon, carcinomatosis. WCC diverticulitis.
■ U&Es
Vomiting and dehydration with gastric and colonic lesions.
■ LFTs
Liver lesions.
■ US
Aortic aneurysm. Lymphadenopathy. Pancreatic pseudocyst.
SPECIFIC INVESTIGATIONS
■ Blood glucose
May be abnormal with pancreatic carcinoma or previos pancreatitis.
■ CT
Pancreatic tumors. Pancreatic pseudocyst. Lymphadenopathy. Aortic aneurysm. Omental deposits. Guided biopsy/FNAC.
■ Barium enema
Carcinoma of the colon. Diverticular disease.
■ Colonoscopy
Carcinoma of the colon. Diverticular disease.
■ Gastroscopy
Carcinoma of the stomach.
■ Laparoscopy
Carcinoma of the ovaries. Omental secondaries. Carcinomatosis peritonei.
■ Biopsy.
UmbiliCAl
Many of the swellings here will already have been described under swellings in other regions of the abdomen. Only those not referred to in those sections will be discussed in the history and examination sections.
SUPeRFiCiAl
Sister Joseph’s nodule (malignant)
HeRniA
Paraumbilical
Umbilical (children)
Stomach
Carcinoma
AbdominAl SwellingS 17
TRAnSVeRSe Colon
Carcinoma
Feces
Diverticular mass
SmAll bowel
Crohn’s disease
Carcinoma
Mesenteric cysts
omenTUm
Secondary deposits, e.g. stomach, ovary
ReTRoPeRiToneUm
Aortic aneurysm
Lymph nodes, e.g. lymphoma, secondaries from testicular
carcinoma
GENERAL INVESTIGATIONS
■ FBC, ESR
Hb carcinoma. WCC diverticular disease.
■ U&Es
Vomiting. Dehydration, e.g. carcinoma of the stomach, carcinoma of the bowel, Crohn’s disease.
■ LFTs
Alkaline phosphatase raised with liver secondaries.
■ US
Aortic aneurysm. Retroperitoneal lymphadenopathy.
SPECIFIC INVESTIGATIONS
■ CT
Aortic aneurysm. Retroperitoneal lymphadenopathy. Omental deposits. Guided biopsy/FNAC.
■ Barium enema
Carcinoma of the colon. Diverticular disease.
■ Colonoscopy
Carcinoma of the colon. Diverticular disease.
■ Gastroscopy
Carcinoma of the stomach.
■ Small bowel enema
Crohn’s disease. Lymphoma. Carcinoma.
■ Laparoscopy
Carcinoma of the ovaries. Omental secondaries. Carcinomatosis peritonei.
■ Biopsy
Benign versus malignant.
AbdominAl SwellingS 19
RigHT And leFT loweR QUAdRAnTS
AbdominAl wAll
Lipoma
Spigelian hernia
lARge bowel
RIGHT LOWER QUADRANT
Appendix mass/abscess
Carcinoma of the cecum
Carcinoma of the ascending colon
Feces
Crohn’s disease
Cecal volvulus
Intussusception
LEFT LOWER QUADRANT
Carcinoma of the sigmoid colon
Diverticular mass
Feces
Sigmoid volvulus
Crohn’s disease
SmAll bowel
Crohn’s disease
Carcinoma
Lymphoma
Ileo-cecal TB
oVARY/UTeRUS/FAlloPiAn TUbe
Ovarian cyst
Ovarian neoplasm
Ectopic pregnancy
Tubo-ovarian abscess
Uterine fibroid
KidneY
See kidney swellings, p. 282.
SPleen (mASSiVe SPlenomegAlY)
See splenomegaly, p. 410.
ReTRoPeRiToneUm
Iliac artery aneurysm Lymphadenopathy
Neoplasm of iliac bone, e.g. osteogenic sarcoma, Ewing’s tumor
GENERAL INVESTIGATIONS
■ FBC, ESR
Hb Crohn’s disease, carcinoma. ESR carcinoma, Crohn’s disease, ileo-cecal TB. WCC appendicitis, diverticulitis.
■ U&Es
Vomiting. Dehydration. Obstruction from carcinoma or Crohn’s disease.
■ LFTs
Alkaline phosphatase with liver secondaries.
■ US
Ovarian lesions. Uterine lesions. Tubo-ovarian abscesses. Pregnancy. Ectopic pregnancy. Iliac artery aneurysms.
Lymphadenopathy. Appendix mass. Crohn’s mass.
■ AXR
Obstruction. Dilated loops of bowel. Ovarian teratoma (teeth, etc.). Erosion of iliac bone – bone tumors.
SPECIFIC INVESTIGATIONS
■ bHCG
Raised in pregnancy.
■ Mantox test
Ileo-cecal TB.
■ CT
Ovarian lesions. Uterine lesions. Abscess. Ectopic pregnancy. Iliac artery aneurysm. Lymphadenopathy. Appendix mass. Bone tumors.
■ Barium enema
Carcinoma. Diverticular disease.
■ Small bowel enema
Crohn’s disease. Carcinoma. Lymphoma.
■ Colonoscopy
Carcinoma (biopsy). Diverticular disease.
■ Laparoscopy
Carcinoma, Crohn’s disease, ileo-cecal TB.
■ Bone scan
Bone tumor.
SUPRAPUbiC
blAddeR
Acute retention
Chronic retention
Carcinoma
UTeRUS
Pregnancy
Fibroids
Carcinoma
bowel
Diverticular mass
Crohn’s disease
Carcinoma
oTHeR
Urachal cyst.
GENERAL INVESTIGATIONS
■ FBC, ESR
Hb tumor. WCC infection.
■ MSU
Red cells. White cells. Organisms, (infection precipitating) retention. Malignant cells with carcinoma.
■ US
Pregnancy. Fibroids. Bladder tumor. Urachal cyst.
SPECIFIC INVESTIGATIONS
■ bHCG
Pregnancy.
■ PSA
Carcinoma of the prostate.
■ Cystoscopy
Bladder tumor. Biopsy.
■ Barium enema
Colonic carcinoma. Diverticular disease. Crohn’s disease.
■ Colonoscopy
Carcinoma. Diverticular disease.
■ CT
Ovarian lesions. Uterine lesions. Bladder lesions. Urachal cyst.