Approach to abdominal wall and groin masses: Clinical sciences

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Introduction0:00–0:37

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 ABCD E assessment to determine if they are stable or unstable.

Unstable patient0:37–1:04

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. All right.
Now that unstable patients are taken care of. Let's talk about stable ones.

Stable Patient1:04–2:11

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. All right, once acute abdomen has been ruled out, assess for other causes of abdominal wall or groin masses.

Abdominal wall hernia2:11–3:47

Starting with abdominal wall or groin hernias. Usually patients come in after noticing a swelling or a bulge in their abdomen or groin area.
These bulges might have started out small but some have grown in size over time. Patients might also 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 spill 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. All right, let's move on to solid masses.

Solid mass3:47–4:14

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 a torn muscle history might reveal a painful mass that was first noticed after trauma to the area.

Rectus sheath hematoma4:14–5:35

The patient might also report taking anticoagulant medications. Physical examination will usually reveal a soft abdomen with a tender nonpulsatile 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, a 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.
Ok. Well, let's go back and talk about desmoid tumors.

Desmoid tumor5:35–6:48

History typically reveals a slow growing mass and some patients may have an inherited genetic disorder like familial adenomatous polyposis.
On physical exam, you will find a fixed firm mass that's nontender. With this presentation, you should consider a desmoid tumor.
Your next step is to order a CT or MRI which will show a relatively homogeneous and well circumscribed mass. Then to confirm the diagnosis, obtain an incisional or core needle biopsy, histopathology showing fibroblastic proliferation and spindle cells with abundant fibrous stroma confirms your diagnosis of a desmoid tumor.
Here's a clinical pearl. The desmoid tumors are also known as aggressive fibromatosis and can develop within the intraabdominal cavity around the intestinal mesentery or within the soft tissue of the limbs.
These tumors are associated with high levels of estrogen. So individuals who are pregnant or taking oral contraceptives are more susceptible to developing them.

Malignancy6:48–8:06

All right, let's go back and talk about malignancy. Next on history.
Patients might report previous diagnosis of cancer like gastrointestinal malignancy as well as weight loss and anorexia.
When it comes to the physical exam, it reveals single or multiple small, fixed firm nodules that are nontender or regional lymphadenopathy if this is the case, you should strongly consider malignant mass.
Your next step is to obtain a biopsy of the mass for a tissue diagnosis. A histopathology report showing malignant cells should confirm your diagnosis.
Some examples include sister Mary Joseph's nodule, which is a metastatic nodule around the umbellus sarcoma of the abdominal wall or lymphadenopathy of the groin.
Here's a clinical pearl. The appearance of lymphadenopathy itself can point you in the right direction to make a diagnosis.
For example, if lymph nodes appear large and rubbery, it is likely from a lymphoma. However, if they are stone hard, you should think about malignancy.
Usually metastasis, finally, softer nodes indicate inflammation or infection. Ok.

Lipoma8:06–8:32

The last of our solid masses are lipomas. These are sporadic benign tumors arising from adipocytes.
History often reveals a painless mass while a physical exam shows a mobile, rubbery superficial solitary mass, that's non tender.
If you see these findings, you are most probably dealing with a lipoma. Let's go all the way back one last time to go over cystic masses of the abdominal wall and the groin.

Abscess, Seroma8:32–9:40

The two main types of cystic masses include abscesses and seromas. In both cases, the patient will report an abdominal or groin mass.
Now, with abscesses, there's usually pain around the area and fever. While seromas are typically painless on exam, you can expect to find an irreducible fluctuant mass.
If you're dealing with an abscess, the mass is going to be tender and you might see cellulitis around it as well as purulent drainage.
In contrast with seromas, there's no tenderness or cellulitis, but there might be some serosanguinous drainage. If you're considering an abscess or a seroma, your next step is to perform an ultrasound to visualize the fluid collection and then aspirate the fluid under ultrasound guidance.
The quality of the fluid will confirm your diagnosis. In other words, if you see pus, you can make your diagnosis of an abscess.
But if you see clear serous fluid, you have a seroma. All right.

Review9:40–10:23

As a quick recap, there are three major types of abdominal wall or groin masses, hernias, solid masses and cystic masses.
First assess for an acute abdomen, which is a surgical emergency. Often arising from an incarcerated or strangulated hernia.
Once you have ruled out an acute abdomen, continue with your workup. If the mass is reducible on exam and you can palpate a fascial defect, it is most likely a hernia.
On the other hand, nonreducible masses that are firm or solid can be rectus sheath, hematoma, desmoid tumor, malignancy or lipoma.
Lastly, cystic masses include abscess or seroma.
Approach to abdominal wall and groin masses: Video | Osmosis