Churchills Pocketbook of Differential Diagnosis

Abdominal Swellings 21
SUBASH KC/NMC-15TH/2014
Ovary/fallopian tube/uterus
The patient herself may feel a lump in the abdomen (ovarian cyst,
fibroid) or notice generalised abdominal swelling, which may be
associated with a massive ovarian cyst or ascites associated with
ovarian cancer. Ectopic pregnancy will present with a missed period
and abdominal pain, bleeding PV, and collapse with hypovolaemic
shock if it ruptures. Salpingo-oophoritis will present with lower
abdominal pain and tenderness and associated fever, and often a
purulent vaginal discharge. Menorrhagia, lower abdominal pain and
dyspareunia may suggest fibroids.
Retroperitoneum
The patient may present having noticed a pulsatile swelling in the
iliac fossa. Pelvic lymphadenopathy may be suspected by history
of removal of a malignant lesion from the lower limb, especially
malignant melanoma. There may be an existing lesion present on the
limb. A dull, boring pain may be suggestive of an iliac bone lesion.
A palpable bony lesion suggests an osteogenic sarcoma or Ewing’s
tumour of bone.
EXAMINATION
The features of most of the lesions described above have been
described in the other sections on abdominal swellings. Only
those findings relevant to the ovary, uterus and fallopian tube will
be described here. Examination may reveal a greatly distended
abdomen, which may be due to a huge ovarian cyst or ascites
associated with an ovarian neoplasm. Huge ovarian cysts are often
smooth and loculated. It is impossible to get below them as they
arise out of the pelvis. Signs of ascites include shifting dullness and a
fluid thrill. With ectopic pregnancy, there may be a palpable mass in
either iliac fossa. This may be associated with shock if rupture of the
ectopic pregnancy has occurred. Shoulder-tip pain may occur from
irritation of the undersurface of the diaphragm with blood. With
tubo-ovarian abscess there may be a palpable mass arising out of the
pelvis, or merely lower abdominal tenderness. Vaginal examination
will reveal tenderness in the pouch of Douglas. Uterine fibroids may
be extremely large and palpable as nodules on the underlying uterus.
GENERAL INVESTIGATIONS
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FBC, ESR
Hb Crohn’s disease, carcinoma. ESR carcinoma, Crohn’s
disease, ileo-caecal TB. WCC appendicitis, diverticulitis.
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U&Es
Vomiting. Dehydration. Obstruction from carcinoma or Crohn’s
disease.
Section A