Abdominal Masses

Authored by , Reviewed by Dr Sarah Jarvis MBE | Last edited | Meets Patient’s editorial guidelines

This article is for Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Abdominal Masses article more useful, or one of our other health articles.


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.

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].

  • 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
  • Cholecystitis - very tender mass
  • Cholangiocarcinoma - moderately tender, irregularly shaped mass
  • Hepatomegaly
  • Liver cancer - firm, lumpy mass
Epigastric
  • Hepatomegaly - firm, irregular mass (also in right costal margin)
  • Pancreatic abscess or pseudocyst
  • Gastric carcinoma
Left upper quadrant
  • Splenomegaly
  • Gastric carcinoma
  • Pancreatic abscess or pseudocyst
  • Disorders of kidney and colon
  • Neurofibroma (rare)
Right flank
  • Hydronephrosis - smooth spongy mass
  • Renal cell carcinoma (smooth, firm, non-tender mass)
Periumbilical
  • Abdominal aortic aneurysm (pulsating mass)
  • Tumour somewhere in the gastrointestinal tract
Left flank
  • Hydronephrosis (smooth spongy mass)
  • Renal cell carcinoma (smooth, firm, non-tender mass)
Right iliac fossa
  • Actinomycosis
  • Amoebic abscess
  • Appendix mass or abscess
  • Caecal/colon cancer or distension
  • Crohn's disease (multiple tender, sausage-shaped masses)
  • Hernia
  • Ileocaecal mass caused by tuberculosis
  • Intussusception
  • Kidney abnormality
  • Ovarian tumour
  • Tumour in intra-abdominal testicle
Suprapubic
  • Distended bladder (firm mass can extend up to the umbilicus in extreme cases)
  • Neuroblastoma (in children and infants)
  • Uteropelvic junction obstruction
Left iliac fossa
  • Diverticulitis (abscess)
  • Hernia
  • Kidney abnormality
  • Ovarian tumour
  • Colorectal cancer
  • Tumour in intra-abdominal testicle
 Pelvis
(should not be able to palpate below mass)
  • Ovarian cyst - smooth, round, rubbery mass
  • Ovarian tumour
  • Pregnancy
  • Uterine fibroids (round, lumpy mass) or malignancy
 

Editor's note

Dr Sarah Jarvis, 8th October 2020

In September 2020, 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 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.

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Further reading and references

  1. Suspected cancer: recognition and referral; NICE Clinical Guideline (2015 - last updated September 2020)

  2. Carnett's test; whonamedit.com

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