Causes and differential diagnosis of the swellings in the Epigastrium

A. PARIETAL SWELLING:- In addition to the swellings discussed under the right hypochondrium i.e. tumours of the skin and subcutaneous tissue, cold abscess, hepatic, subphrenic and perigastric abscesses, the swelling peculiar to this region is the epigastric hernia.

Epigastric hernia- The usual sufferer is a strong muscular labourer. He presents with a small round swelling exactly in the midline anywhere between the xiphisternum and umbilicus. In the first stage, it is sacless herniation of the extraperitoneal fat through a weak spot in the linea alba. There is no symptom at this stage. In the second stage, a pouch of peritoneum is drawn after it. In the last stage, a small tag of omentum gets into the sac and becomes adherent to it. At this stage the patient complains of dragging pain, discomfort or pain after food, not unlike those in peptic ulcer.

B. INTRA-ABDOMINAL SWELLINGS:- They occur in connection with the:

1. Liver and Subphrenic abscess-

2. Stomach and Duodenum-

a) Congenital pyloric stenosis- Babies about 2 to 4 weeks old when present with projectile vomiting after meals, the diagnosis becomes obvious. On examination visible peristalsis of the stomach is always seen. Sometime a definite lump may be felt at the pylorus of the stomach.

b) Subacute perforation of peptic ulcer-

c) Carcinoma of the stomach-

3. Transverse colon- Intussusception, diverticulitis, Hyperplastic tuberculosis and neoplasms are the causes of swellings which may originate from the transverse colon. In intussusception there will be emptiness at the right iliac fossa. The patient complains of colicky pain, a lump in the epigastrium and "red current jelly" in the stool. In inflammatory conditions a tender and irregular mass may be felt. In carcinoma the swelling is the presenting symptom. The swelling is irregular, hard and may be mobile above downwards and very slightly in the sideways or may be fixed. Anaemia, anorexia and occult blood in the stool are the features which helps in the diagnosissideways or may be fixed. Barium enema X-ray reveals constant 'filling defect' of the colon.

4. Omentum- In the tubercular peritonitis, the omentum is rolled up to form a transverse ridge in the epigastrium. Enlarged lymph nodes or adherent coils of intestine are also come across in this condition.

5. Pancreas- It hardly gives rise to a palpable swelling. The condition that forms lump in connection with this organ is the pseudopancreatic cyst. True cyst of the pancreas is extremely rare. The pseudocyst is a collection of fluid in the lesser sac of the peritoneal cavity resulting from acute pancreatitis or trauma. It forms a smooth rounded swelling with fluctuation test positive. X-ray with barium meal will show the exact position of the swelling which is situated behind the stomach and is best seen in the lateral X-ray.