Mass in right hypochondrium or right hypochondrial mass can be due to several reasons. Following are differential diagnoses of right hypochondrial lump.
Based on abdomen examination protocol, we would examine the swelling of abdomen
General Physical Examination
Appearance: Anemic, jaundiced or emaciated, Lymph nodes, especially supraclavicular.
- Overlying skin
- Position, size, shape and surface of the swelling
- Movement of swelling on respiration
- Check sites of hernia
- Observe scrotum for any fullness
- Note the local temperature
- Is swelling tender?
- Muscular rigidity
- Confirming positive findings of inspection
- Note margins on palpation. Can you get around the margin? Well or ill-defined.
- Consistency: Soft, firm or hard. Hard swellings are usually malignant, soft swelling may be cystic.
- Mobility: This should be determined by hand in all directions, i.e. from side to side and above downward.
- Is swelling parietal or intra-abdominal?
This can be found out by making the abdominal muscles taut by raising the shoulders or the legs.
If the lump becomes less prominent is intra-abdominal. If it becomes more prominent it is partial.
If the lump is mobile over the contracted muscles it is superficial to the muscles and if it is fixed, it is adherent to the muscle.
- Hernial sites for expansile impulse on coughing
- Pulsations if present: expansile (aortic) or transmitted (lump over aorta)
- Dull or resonant
For rub (perisplenitis and perihepatitis)
Swellings in the Abdominal Wall
1. Fluctuant swelling with no signs of inflammation
2. Swelling becomes prominent when the abdominal muscles contract
3. Irregularity in the affected rib or deformity of the spine
1. It moves with respiration but is not mobile sideways
2. The swelling is continuous with the liver dullness without a band of colonic resonance
1. Oval smooth swelling, the size of an egg
2. Moves with respiration, can be moved sideways but cannot be pushed down into the loin (like kidney swelling)
Chronic Cholecystitis and Cholelithiasis
1. Pain over the right rectus muscle radiating to the inferior angle of scapula, aggravated after fatty meals. Often the patient makes an attempt to get relief by frequent belching or vomiting but relief is seldom complete.
2. Gall bladder may be palpable.
3. Murphy’s sign is positive: i.e. Tenderness under the right costal margin at the lateral border of the rectus muscle when the patient takes a deep breath. This occurs due to the descent of the inflamed gallbladder which touches the examiner’s fingers. If a stone is present in the common bile duct there is a triad of intermittent colic, intermittent jaundice and fever with chills and rigors. By Courvoisier’s law, gall bladder is not palpable.
1. Pain in the right hypochondrial region referred to the shoulders
2. Diffuse tender swelling in the right hypochondrial region
3. Signs of septicemia: High fever with rigors, sweating and marked tachycardia
4. Screening: Raised and fixed diaphragm with gas under it
5. Features of the causative condition e.g. perforated peptic ulcer, liver abscess
Stomach and Duodenum
Carcinoma of Pylorus:
1. There is irregular firm lump which moves on respiration
2. Patient is usually elderly and has anorexia and weight loss
3. Barium meal would show filling defect
Sub-Acute Perforation of a Peptic Ulcer
1. Localized, tender, inflammatory mass may be present with a central abscess
2. History of peptic ulcer
3. Barium meal would reveal the ulcer
Hepatic Flexure of Colon
This usually causes a lump in the right iliac fossa which may be drawn towards the right hypochondriac region by fibrosis.
Carcinoma of Colon
1. This commonly occurs in men above the age 40 years
2. There is alternate diarrhea and constipation.
3. The lump is irregular, firm and moves poorly on respiration
4. Occult blood may be present in stools
5. Filling defect may be seen on barium enema.
1. There is sudden intermittent abdominal pain with vomiting.
2. Absolute constipation may be replaced later by passage of blood and mucus (red current jelly) per anum without fecal odour.
3. There may be curved, sausage shaped lump in the line of the colon with its concavity towards the umbilicus. The lump may harden under examining fingers synchronously with an attack of screaming.
4. Barium enema would show typical pincer shaped ending of the radio-opaque material.
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