Churchills Pocketbook of Differential Diagnosis

Abdominal Swellings 15
Stomach
A baby may present with projectile vomiting. The infant thrives for
the first 3–4 weeks of life and then develops projectile vomiting
after feeds. The first-born male child in a family is most commonly
affected. There may be a history of a familial tendency, especially on
the maternal side.
Retroperitoneum
A history of backache may suggest an aortic aneurysm or
the patient may complain of a pulsatile epigastric swelling.
Backache may also be a presenting symptom of retroperitoneal
lymphadenopathy.
EXAMINATION
SUBASH KC/NMC-15TH/2014
Abdominal wall
A soft, lobulated mass suggests a lipoma. It will be mobile over the
tensed abdominal musculature. A fatty, occasionally tender, nonmobile
swelling in the midline will suggest an epigastric hernia.
The majority of epigastric hernias are composed of extraperitoneal
fat, although there may be a sac with bowel contents. A cough
impulse will be palpable. The swelling may be reducible. Hard,
irregular, fixed lumps in the abdominal wall suggest metastatic
deposits, especially if there is a history of carcinoma of the breast or
bronchus.
Retroperitoneum
An aneurysm presents as a pulsatile expansile mass. Check the
distal circulation (emboli, associated peripheral ischaemia).
Retroperitoneal lymph node metastases from testicular cancer
may present as a large retroperitoneal mass. Check the testes for
swellings. Check all other sites for lymphadenopathy (especially
the left supraclavicular node). Lymphadenopathy may also result
from lymphoma. Check for lymphadenopathy elsewhere and
for splenomegaly. A hard, craggy, mobile mass, especially in
the presence of ascites, suggests omental secondaries (ovary,
stomach – check for Virchow’s node, i.e. left supraclavicular
node).
GENERAL INVESTIGATIONS
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FBC, ESR
Hb carcinoma of the stomach, carcinoma of the colon,
carcinomatosis. WCC diverticulitis.
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U&Es
Vomiting and dehydration with gastric and colonic lesions.
Section A