Right Hypochondrium

Causes of swelling
a. Parietal swellings :
Swelling of skin and subcutaneous tissue: Sebaceous cyst, lipoma, fibroma, neurofibroma,
angioma etc.
Special Parietal Swellings
 Cold abscess : arising from caries of ribs (commonly ) or spine (rarely)
Features: soft cystic and fluctuating swelling with no signs of inflammation.
Irregularity in the affected rib or deformity of spine clinches the diagnosis.
 Hepatic, subphrenic or perigastric abscess may burrow through anterior abdominal wall to
form a parietal abscess.

b. Intra – Abdominal swellings

May occur in connection with:

1. LIVER
Enlargement of liver is determined by palpating its lower border and percussing its upper limit.
Hepatic swellings are continuous with liver dullness and move up and down with respiration.
Some common causes are:
 Congenital Riedel’s lobe: tongue shaped projection from the lower border of the right lobe of the
liver.
- Likely to be mistaken with enlarged gallbladder but it is more wide and flat and lacks
the spherical outline of the distended gall bladder.
-It is a simple anatomical variation or secondary to inflammation or attachment to other
tissue rather than a congenital anomaly.

 Amoebic Hepatitis and Abscess : Patient who has suffered from amoebic dysentery months or
years ago presents with a complaint of pain in the right hypochondrium often referred to the tip
of shoulder with presence of cough , fever and chills

Clinical Feature:

 pain in right hypochondrium; intense , continuous or stabbing type.

 When swelling can be felt, abscess has probably developed and the
swelling becomes softer with extreme tenderness.
 The patient looks pale and slightly icteric.
 Liver is palpable and tender.
 Subcutaneous edema which pits on edema is an extra finding.
 Suppurative pyelophlebitis
 rare but very serious complication of gangrenous appendicitis associated with
fever , rigor and jaundice.
 The liver becomes palpable and tender.

 Gumma of the liver: soft, non-cancerous growth resulting from the tertiary stage of syphilis.
 Physical examination shows abdominal distension and tenderness.

 Hydatid cyst:
History: A sheep farmer otherwise healthy complains of a gradually enlarging painful mass in
the right upper quadrant.
Clinical Features
 Asymptomatic palpable liver with classical thrill (hydatid thrill) elicited by three-
finger test.
 Jaundice and dull aching pain.
 Discomfort in right upper quadrant ;dyspepsia ; weight loss, fatigue , vomiting
 Occasionally spleenomegaly, pleural effusion , cholangitis are present.
 Camellote sign: Following intrabiliary rupture, gas enters into cyst causing
partial collapse of the cyst wall
 Carcinoma of the liver: Primary carcinoma is rare. It may be a hepatoma or cholangioma.
Secondary carcinoma of the liver is much commoner
Clinical Feature
 Painless mass in right hypochondriac region with loss of appetite and weight.
 Liver is enlarged, irregular with nodules of varying size and shape and becomes
hard.
 Jaundice
 Ascites often is massive, spleenomegaly and features of portal hypertension
may be present.
 Hepatic thrill and bruit is present.
 Features of chronic liver disease - jaundice, dilated veins, palmar erythema,
gynecomastia, testicular atrophy, variceal bleed, encephalopathy

 Melanotic carcinoma of the liver: it occurs secondary to similar growth on the palm, foot or
eye. And enlarged liver with malignant melanoma anywhere in the body should clinch the
diagnosis.

2. GALL BLADDER
1. Oval smooth swelling, the size of an egg
2. Moves with respiration, can be moved sideways but cannot be pushed down into the loin (like
kidney swelling)

 Chronic Cholecystitis and Cholelithiasis

  Pain over the right rectus muscle radiating to the inferior angle of scapula,
aggravated after fatty meals. Often the patient makes an attempt to get relief
by frequent belching or vomiting but relief is seldom complete.
 Gall bladder may be palpable.
 Murphy’s sign is positive
 If a stone is present in the common bile duct there is a triad of intermittent
colic, intermittent jaundice and fever with chills and rigors. By Courvoisier’s law,
gall bladder is not palpable.

3. SUBPHRENIC ABSCESS
 Pain in the right hypochondrial region referred to the shoulders.
 Diffuse tender swelling in the right hypochondrial region.
 Signs of septicemia: High fever with rigors, sweating and marked tachycardia.
 Screening: Raised and fixed diaphragm with gas under it.
 Features of the causative condition e.g. perforated peptic ulcer, liver abscess.

4. STOMACH AND DUODENUM

 Carcinoma of Pylorus:
 There is irregular firm lump which moves on respiration
 Patient is usually elderly and has anorexia and weight loss.
 Barium meal would show filling defect

 Sub-Acute Perforation of a Peptic Ulcer

 Localized, tender, inflammatory mass may be present with a central abscess.
 History of peptic ulcer
 Barium meal would reveal the ulcer

5. HEPATIC FLEXURE OF COLON

 Hypertrophic Tuberculosis
This usually causes a lump in the right iliac fossa which may be drawn towards the right
hypochondriac region by fibrosis.
 Attacks of abdominal pain with intermittent diarrhoea are the usual symptoms.
 The ileum above the partial obstruction is distended, and the stasis and consequent
infection lead to steatorrhoea, anaemia and loss.

 Carcinoma of Colon
 This commonly occurs in men above the age 40 years
 There is alternate diarrhea and constipation.
 The lump is irregular, firm and moves poorly on respiration.
 Occult blood may be present in stools.
 Filling defect may be seen on barium enema.

 Intussusception
 There is sudden intermittent abdominal pain with vomiting.
  Absolute constipation may be replaced later by passage of blood and mucus (red
current jelly) per anum without fecal odour.
 There may be curved, sausage shaped lump in the line of the colon with its concavity
towards the umbilicus. The lump may harden under examining fingers synchronously
with an attack of screaming.
 Barium enema would show typical pincer shaped ending of the radio-opaque material.

6. KIDNEY
Features of swelling:
 reniform swelling
 Moves very slightly with respiration as it comes down a little at the height of
inspiration
 Ballotable
 Sickening sensation is felt during manipulation
 A hand can be insinuated between the upper pole of swelling and the coastal margin
 Percussion note will reveal resonant in front of a kidney swelling as coils of intestine
and colon will always be infront of a kidney

7. SUPRARENAL TUMORS
 In the adrenal cortex, the causative lesion may be bilateral hyperplasia, a benign adenoma or a
malignant carcinoma
 In the medulla pheochromocytoma which is a benign tumour, a benign ganglio-neuroma or
malignant neuroblastoma may appear.
 Clinical Features
 Lesions of cortex : excess of aldosterone causes aldosteronism, excess of cortisol causes
Cushing’s syndrome and excess of estrogen causes feminization in the female.
 Lesions of medulla : depend on amount of adrenaline and not adrenaline produced.