Introduction
Swellings in the upper midline of the abdomen—epigastric or umbilical—can point to gastrointestinal, pancreatic, vascular, or retroperitoneal causes. This article explores the common and critical differential diagnoses, how to clinically differentiate them, and the investigations that follow.
Anatomical Overview
- Epigastric region: stomach, pancreas, transverse colon, aorta
- Umbilical region: small bowel, omentum, mesentery, lymph nodes
- Overlap with retroperitoneum and deep GI structures
Causes of Epigastric Swellings
1. Stomach
- Pyloric stenosis: Common in infants; olive-like swelling, projectile vomiting
- Gastric carcinoma: Hard, craggy, immobile, irregular
2. Transverse Colon
- Faecal mass: Doughy, mobile, indents on pressure
- Carcinoma: Firm, irregular, may be mobile or fixed
3. Pancreas
- Pseudocyst: Post-pancreatitis, mildly tender, smooth
- Pancreatic carcinoma: Deep, hard, irregular, fixed, often with jaundice
4. Aortic Aneurysm
- Smooth, pulsatile, expansile swelling
- Risk of rupture if >5 cm
- Detected by ultrasound or CT angiography
5. Retroperitoneal Masses
- Lymphadenopathy: Firm, immobile, rubbery
- Dermoid cyst: Rare, smooth, deep-seated, sometimes recurrent after surgery
Causes of Umbilical Swellings
1. Stomach Tumors
- Leiomyoma or carcinoma presenting as epigastric/umbilical mass
2. Transverse Colon
- Again, carcinoma or impacted feces in central location
3. Retroperitoneum
- Aortic aneurysm (midline, expansile)
- Lymphoma (deep, irregular, immobile)
4. Small Bowel
- Crohn’s disease: Thickened loops, mass with pain, sometimes with systemic symptoms
5. Omentum
- Secondary tumors (carcinomatosis): Pancake-like, irregular, mobile
- Common in ovarian carcinoma, stomach or colon cancers
6. Mesenteric Cyst
- Cystic, fluctuant, mobile side-to-side but not vertically
Clinical Differentiation of Masses
| Feature | Pseudocyst | Aortic Aneurysm | Lymphadenopathy | Gastric Tumor | Faecal Mass |
|---|---|---|---|---|---|
| Tenderness | ± mild | ± | No | Often not | No |
| Consistency | Smooth | Smooth, pulsatile | Rubbery | Craggy, hard | Doughy |
| Mobility | Fixed | Expansile | Fixed | Immobile | Mobile |
| Percussion | Dull | Resonant or dull | Variable | Dull | Resonant |
| Imaging | USG/CT | USG/CT Angio | CT | Gastroscopy | X-ray |
Clinical Red Flags
- Hard, irregular, non-mobile swellings
- Expansile, pulsatile midline mass → aneurysm risk
- Associated signs: jaundice, weight loss, GI bleeding
- Signs of obstruction or peritonitis
- Recurrent swelling post-surgery → dermoid or lymphadenopathy
Key Investigations
| Test | Indications |
|---|---|
| FBC | Anemia (cancer), leukocytosis (infection) |
| WCC | Lymphomas, Crohn’s, sepsis |
| LFTs | Pancreatic or hepatic involvement |
| Ultrasound | Aortic aneurysm, cystic lesions |
| CT Scan | Pancreas, mesentery, retroperitoneum, omentum |
| Gastroscopy | Gastric tumors |
| Colonoscopy | Colonic tumors, obstructive symptoms |
| Small Bowel Enema | Crohn’s or small bowel tumors |
| Barium Enema | Colonic masses |
| Tumor markers | CA 19-9, CEA, AFP depending on suspected source |
Management by Cause
Aortic Aneurysm
- Monitor if <5 cm
- Surgery if symptomatic or >5 cm
- Endovascular repair (EVAR)
Pancreatic Pseudocyst
- Observation or drainage depending on size/symptoms
Pancreatic Carcinoma
- Staging, surgery (Whipple), or palliative chemo
Lymphadenopathy
- FNAC or biopsy to confirm
- Treat underlying lymphoma or infection
Crohn’s Disease
- Medical management, immunosuppressants
- Surgery if complicated
Gastric/Colon Cancer
- Gastrectomy or hemicolectomy
- Chemo ± radiotherapy
FAQs
Can you feel your stomach cancer externally?
Only if it has grown significantly or causes visible swelling.
How serious is a pulsatile lump in the abdomen?
Very. It may be an abdominal aortic aneurysm and can rupture.
Is Crohn’s disease a cause of swelling?
Yes—especially thickened bowel loops or inflammatory masses.
Do pseudocysts always need treatment?
No—most resolve spontaneously unless symptomatic or infected.
What’s the best scan for abdominal swellings?
Ultrasound is good first-line; CT gives detailed cross-sectional views.
Conclusion
Epigastric and umbilical swellings are diagnostically rich regions, housing everything from benign cysts to vascular emergencies and advanced malignancies. Accurate clinical assessment, combined with targeted imaging, is the key to timely diagnosis and effective management.
