Examine this patient's abdomen.


Patient 1

The patient has an epigastric mass. Differential diagnosis:

· carcinomaof the stomach: look for supraclavicular lymph nodes, hepatomegaly: comment on pallor and asthenia.

· Carcinoma of the pancreas: look for jaundice.

· Aneurysm of the abdominal aorta: look for pulsatile mass; check femoral and foot pulses; auscultate over the mass and the

Iemoral pulses (see p. 328).

· Retroperitoneal lymphadenopathy (lymphoma).

Patient 2

The patient has a mass in the right lilac fossa. Differential diagnosis:

· Crohn's disease: look for mouth ulcers; tell the examiner that you would like to look for fistulas and take a history for chronic

diarrhoea (see p. 575).

· Carcinoma of the caecum: look for hard mass, lymph nodes.

· Look for lymph nodes elsewhere (see pp 569-71); feel for liver and spleen: examine the drainage area of iliac lymph nodes

(such as the leg, perianal area, external genitalia; do a rectal examination).

· Transplanted kidney: comment on the laparotomy scars, stigmata of renal failure and artificial arteriovenous fistulas.

· Appendicular abscess.

· lleocaecal abscess, particularly in Asians.

· Ovarian tumours (must be mentioned as a differential diagnosis in female patients).

Less common causes of masses in the right iliac fossa:

· Amoebiasis.

· Carcinoid (ileal).

· Actinomycosis.

· Ectopic kidney.

Patient 3

The patient has a mass in the left lilac fossa. Differential diagnosis:

· Diverticular abscess: look for a tender, mobile mass.

· Carcinoma of the colon: look lor hepatomegaly; tell the examiner that you would like to do a per rectum examination.

· Faecal mass (the mass may be moulded by pressure).

· Ovarian tumour (in females).

· Iliac lymph nodes: look for other lymph nodes, liver and spleen; examine the drainage areas.

· Transplanted kidney: comment on the laparotomy scar, look for signs of renal failure, arteriovenous fistulas (see pp 603-5).

Note. The investigation of first choice in such patients is abdominal ultrasonography.

Robin Warren, Pathologist at Royal Perth Hospital in Western Australia, and Barry J. Marshall discovered that Helicobacter pylori

causes peptic ulcer disease (Lancet 1983; i: 1273-5). In 1984, Marshall infected himself by drinking a pure culture of H. pylori. After

feeling fine for 5 days he experienced nausea and vomiting. Histology confirmed acute gastritis. In 1995 he received the Albert

Lasker Clinical Medical Research Award. H. pylori has also been implicated in the causation of gastric cancer in Japanese people.