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Snapshot diagnosis - what's causing this painful abdominal mass?

Dr Hercules Robinson describes a case where his instinctive suspicion of a malignancy thankfully proved groundless

Dr Hercules Robinson describes a case where his instinctive suspicion of a malignancy thankfully proved groundless

The patient

I was called to seen a 71-year-old man at home because of abdominal pain. He complained of increasingly severe upper abdominal pain over the last few weeks. He had developed anorexia with weight loss of over one stone and had been troubled by sweating, especially at night.

First instinct

He looked ill and had a visible mass in the right upper quadrant. On examination, he had a slight fever. There was a tender palpable mass in his right upper abdominal quadrant with guarding, but no rebound tenderness. There was a midline abdominal scar following peptic ulcer surgery some years before. My first thought was that he had a malignancy, mostly probably a bowel cancer with liver metastases.

Differential diagnosis

• Hepatic secondaries from a bowel primary

Then more unusual causes

• Hepatocellular carcinoma – uncommon in western Europe

• Hepatic adenoma – mainly in females

• Hepatic cysts or abscess, amoebic or hydatid

• Bile duct tumours, cholangiocarcinoma

Getting on the right track

On questioning, he did not give a history of any change in his bowel habit. He did not have a history of hepatitis B infection. He had not travelled abroad for many years, and had never travelled outside Europe. He did have a history of severe COPD, and had received a prolonged course of steroids.

The hidden clue

His prolonged course of steroids would have lowered his immunity and made an infection more likely. I did not pick this up and felt a malignancy was the most likely cause. The outcome was a pleasant surprise.

Outcome

I arranged admission to our local general hospital. A plain X-ray revealed a mass displacing the transverse colon. An abdominal ultrasound scan revealed a hepatic mass. He was treated with intravenous antibiotics. He was referred onwards to a major hospital with CT scanning facilities. The CT scan revealed a large cyst. This cyst was drained using CT guidance. The offensive purulent content was sent for analysis. It was found to be sterile with no evidence of amoebiasis or hydatid disease. The drain was left in situ and gradually the cyst emptied. He gradually recovered his health. No firm diagnosis was made other than hepatic abscess.

Dr Hercules Robinson is a GP in Caithness

What's causing this painful abdominal mass? What's causing this painful abdominal mass?

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