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  • • Myriad of conditions manifest clinically with a palpable abdominal wall mass

    • Key to diagnosis is careful history and physical exam

    • Asymptomatic deep abdominal wall mass may be incidentally discovered on imaging studies

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Epidemiology

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  • • Rectus hematomas may arise following abdominal wall trauma or occur spontaneously in patients receiving anticoagulant therapy

    • Spontaneous abdominal wall metastases are most commonly associated with lung and pancreatic adenocarcinoma

    • Any intra-abdominal malignancy can extend into the abdominal wall or secondarily seed laparotomy incisions

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Symptoms and Signs

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  • Rectus hematoma: An exquisitely tender mass that becomes more painful with flexion of the abdominal wall with surrounding ecchymosis is the classic finding

    Deep wound infection or abdominal wall abscess: Signs of infection or inflammation (erythema, induration, tenderness, exudate)

    Abdominal wall hernia: A reducible bulge that develops with the Valsalva maneuver

    Soft-tissue neoplasms: Most are asymptomatic with a slow growth pattern

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Laboratory Findings

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  • • Coagulopathy may be present in patients with rectus sheath hematoma

    • Leukocytosis with deep wound infection or abdominal wall abscess

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Imaging Findings

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  • • Plain abdominal films are usually normal

    • US can differentiate between a solid and a fluid-filled mass and reliably demonstrate the presence of abdominal viscera in the case of an incarcerated abdominal wall hernia

    • CT will characterize the mass and differentiate between hematoma, fat, soft-tissue, and fluid-density lesions

    • MRI is best method to evaluate soft-tissue masses suspicious for sarcoma

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  • • Rectus hematoma

    • Tumor metastasis

    • Desmoid tumor

    • Deep wound infection

    • Abdominal wall abscess

    • Soft-tissue sarcoma

    • Incisional hernia

    • Interparietal hernia

    • Spigelian hernia

    • Lipoma

    • Hemangioma

    • Fibroma

    • Endometrioma

    • Stitch abscess

    • Stitch granuloma

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Rule Out

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  • • Tumor metastasis

    • Hernia

    • Soft-tissue sarcoma

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  • • Careful history

    • -Malignancy (metastasis)

      -Constitutional symptoms (metastasis)

      -Trauma (hematoma)

      -Cesarean section (desmoid tumor, endometrioma)

      -Familial adenomatous polyposis (desmoid tumor)

      -Prior laparotomy (incisional hernia)

      -Fever and chills (deep wound infection or abdominal wall abscess)

    • Careful physical exam

    • -Mass reducible (hernia)

      -Mass expanding (hematoma)

      -Pain, erythema, and induration (deep wound infection or abdominal wall abscess)

    • Obtain CT or MRI when solid mass is suspicious for abdominal wall metastasis, soft-tissue sarcoma, or desmoid tumor

    • Perform percutaneous biopsy for solid mass

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When to Admit

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  • • Uncomplicated abdominal wall mass work-up may be performed as an outpatient

    • Patients with deep wound infection or abdominal wall abscess need to be admitted for drainage and antibiotic therapy

    • Patients with complicated hernia (incarcerated, strangulated, small bowel obstruction) require admission for urgent surgical treatment

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  • Rectus sheath hematoma: Correct coagulopathy, avoid antiplatelet medications, control pain, and provide expectant management

    Soft-tissue mass: Radiographic characterization with percutaneous or incisional biopsy to establish the diagnosis followed by definitive surgical excision

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