Causes and differential diagnosis of the swellings in the Right Hypochondrium
A. PARIETAL SWELLING:- Besides the swellings involving the skin and subcutaneous tissue e.g. sebaceous cyst, lipoma, fibroma, neurofibroma, angioma etc. as may occur in other situation, the special parietal swelling is a cold abscess arising from caries of the rib (commonly) or spine (rarely). It gives rise to a soft cystic and fluctuating swelling with no signs of inflammation. Irregularity in the affected rib or deformity of the spine, if present, clinches the diagnosis. An X-ray is helpful. A heaptic, subphrenic or perigastric abscess may burrow through the anterior abdominal wall to form a parietal abscess.
B. INTRA-ABDOMINAL SWELLINGS:- They may occur in connection with:-
Liver
Gallbladder
Subphrenic space
Pylorus of the stomach and duodenum
Hepatic flexure of the colon
Right kidney
Right suprarenal gland
1. Liver- Enlargement of the liver is determined by palpating its lower border and percussing its upper limit. Hepatic swellings are continuous with the liver dullness and move up and down with respiration. It is difficult to move the swellings sideways. Causes of enlargement of liver are many, but the important surgical conditions are considered here.
2. Gallbladder- It feels as an oval smooth swelling which is tense and cystic. It comes out of the lower border of the liver and moves freely up and down with respiration along with liver. The swellings may be tender depending on the amount of inflammation present. It can be moved sideways a little. It is not ballottable as a kidney swelling.
3. Subphrenic abscess- There are innumerable causes of accumulation of pus under the diaphragm. Majority follow intraperitoneal conditions e.g. perforated peptic ulcer (commonest), following abdominal trauma, following operations on biliary tract, following operation on the stomach or colon and acute appendicitis. Diagnosis mainly depends on suspicion. The patient looks very much anxious and drawn. They may complain of anorexia and nausea. A rise of temperature is always associated with. But its degree varies- there may be high rise of temperature with rigor, sweating and rapid pulse, or there may be slight rise of temperature but the patient always looks abnormally ill. Rigor only occurs when there is concomitant pylephlebitis or a liver abscess. More important indicator is the pulse rate which always becomes abnormally fast irrespective of the temperature. Tachypnoea is also often present. Pain is not a very prominent feature and should not be much relied on so far as the diagnosis is concerned. If present, it usually becomes localized to the site of lesion. Right hypochondrium or epigastrium is the usual site of pain. Very occasionally it may be complained of in the lower part of thorax, right lumbar region or even referred to the right shoulder. Jaundice is not a sign of this condition but if present indicates obstruction of the common bile duct with a stone or suppurative pylephlebitis.
Tenderness just below the costal margin or xiphoid process or more precisely tenderness over the 11th intercostal space though suggestive of this condition yet may be absurd. X-ray screening will show sluggish movement of the diaphragm. The diaphragm becomes raised and gas may be found beneath it. Aspiration of pus from the subdiaphragmatic space leaves no doubt about the diagnosis.
4. Pylorus of the stomach and duodenum-
(a) Carcinoma- of this region usually gives rise to obstructive symptoms. Barium meal X-ray will show 'filling-defect' which is very diagnostic.
(b) Subacute perforation of peptic ulcer- forms a localized tender mass which is a rare condition. The patient gives history suggestive of peptic ulcer and sudden excruciating pain before formation of mass. It may lead to a subphrenic abscess.
5. Hepatic flexure of a colon:
(a) Intussusception
(b) Hypertrophic tuberculosis- This usually starts in the ileo-caecal region and may move up into this region and may move up into this region.
(c) Carcinoma of this part of the colon- may present with a lump only or with anaemia, anorexia and occult blood in the stool. The lump is irregular and hard with slight or no movement. Barium enema X-ray reveals constant filling defect which is very diagnostic.
6. Kidney- The features of a kidney swelling are: (i) It is a reniform swelling; (ii) It is ballottable; (iii) it moves very slightly with respiration as it comes down a little at the height of inspiration; (iv) A sickening sensation is often felt during manipulation; (v) A hand can be easily insinuated between the upper pole of swelling and the costal margin; (vi) Percussion will reveal resonant note in front of the kidney swelling as coils of intestine and colon will always be in front of the kidney.
7. Suprarenal tumours- Suprarenal gland has got a cortex and a medulla. In the adrenal cortex the causative lesion may be bilateral hyperplasia, a benign adenoma or a malignant carcinoma. In the medulla phaeochromocytoma, which is usually a benign tumour, a benign ganglio-neuroma or malignant neuroblastoma may appear. Hyperplasia of the medulla, though described, is exceedingly rare. The clinical syndromes vary with the hormones which are produced. Thus in the lesions of the cortex, excess of aldosterone causes aldosteronism, excess of cortisol causes Cushing's syndrome, excess of androgen causes adrenogenital syndrome and excess of estrogen causes feminisation in the male. In medullary tumours the clinical features depend on the relative amounts of adrenaline and noradrenaline which are produced.