Approach to abdominal wall and groin masses: Clinical sciences

Abdominal wall or groin masses are common surgical symptoms that arise due to hernias, traumatic injuries, neoplasms, or infections. Each of these typically presents with a unique set of clinical features that can help you differentiate one from another. For example, some masses are reducible, while others are hard like a solid mass, or soft like a cystic mass. So, getting a good history and a thorough physical exam is very important in narrowing down your differential.

The first step in assessing a patient presenting with an abdominal wall or groin mass is to perform the ABCDE assessment to determine if they are stable or unstable.

If the patient is unstable, start acute management right away by stabilizing the airway, breathing, and circulation. Make sure to obtain IV access, initiate IV fluid resuscitation, and keep the patient NPO.

Alright, now that unstable patients are taken care of, let’s talk about stable ones.

Your first step here is to obtain a focused history and physical exam. Start by assessing for an acute abdomen, which is always a surgical emergency. These patients typically report severe abdominal or groin pain around the mass, as well as nausea, vomiting, constipation, or obstipation, which are signs of bowel obstruction.

Physical exam often reveals a distended abdomen with signs of peritonitis, such as diffuse tenderness with rebound pain and guarding, along with an irreducible mass.

These are classic findings of incarcerated or strangulated hernias with acute abdomen. Since we are talking about a surgical emergency, these patients need operative intervention right away to relieve the obstruction and prevent the progression of abdominal sepsis from bowel ischemia and necrosis. Once abdominal sepsis occurs, patients can quickly deteriorate and become unstable.

Alright, once acute abdomen has been ruled out, assess for other causes of abdominal wall or groin masses starting with abdominal wall or groin hernias.

Usually, patients come in after noticing a swelling or a bulge on their abdomen or the groin area. These bulges might have started out small, but some may have grown in size over time. Patients also might report that the bulge grows while coughing, straining, or standing for a prolonged period of time. Finally, history might reveal localized pain, pressure, or heavy sensation around the bulge. As for the exam, you will find a reducible swelling, as well as the protrusion of a soft mass over a fascial defect. When you ask the patient to cough or perform the Valsalva maneuver, the mass will protrude or get larger. If you see these findings, you can diagnose the patient with an abdominal wall or groin hernia.

Here’s a clinical pearl! There are many types of hernias categorized by their anatomic location. In general, groin hernias are more common and include femoral and inguinal hernias. On the other hand, abdominal wall hernias are often referred to as ventral or incisional hernias. Common abdominal hernias include epigastric, umbilical, and Spigelian, which occur at the lateral edge of the rectus muscle below the arcuate line deep to the external obliques. Incisional hernias can occur anywhere on the abdominal wall where a surgical incision has been made.

Alright, let’s move on to solid masses.

If the patient reports an abdominal or groin mass, and you find that it’s irreducible and feels firm on the exam, consider a solid mass. The four main types of solid masses that should make up your differential diagnoses include rectus sheath hematoma, desmoid tumors, malignancy, and lipomas.

First, let’s talk about rectus sheath hematomas. These occur when blood accumulates in the rectus abdominis sheath from a ruptured epigastric vessel or torn muscle. History might reveal a painful mass that was first noticed after trauma to the area. The patient might also report taking anticoagulant medications. Physical examination will usually reveal a soft abdomen with a tender non-pulsatile mass, sometimes with extensive ecchymosis around the area. These findings should lead you to consider a rectus sheath hematoma.

In this situation, your next step is to order imaging like a CT with IV contrast to visualize the mass, as well as labs, including CBC, PT, PTT, and INR to assess the patient’s coagulation status. Typically, the CT scan shows a spindle-shaped mass behind the rectus abdominis muscle, possibly with a hyperdense focus of contrast extravasation indicating acute bleed. Additionally, labs might reveal low hemoglobin and prolonged PT, PTT, and INR, indicating coagulopathy. These findings confirm your diagnosis of a rectus sheath hematoma.

Okay, let's go back and talk about desmoid tumors.