Introduction
A lump or swelling in the upper abdomen can arise from the liver, gallbladder, spleen, kidneys, pancreas, bowel, or retroperitoneum. This article breaks down each region's causes, diagnostic signs, and how to clinically distinguish one from the other.
Clinical Key Principles
- Liver and spleen masses move with respiration, dull to percussion
- Renal masses: ballotable, resonant (overlying bowel gas)
- Retroperitoneal masses: fixed, non-mobile
- Bowel masses: often mobile and resonant
- Ask patient to raise head — abdominal wall lumps persist, intra-abdominal swellings recede
Right Upper Quadrant (RUQ) Swellings
1. Liver
- Riedel’s lobe: Normal anatomical variant
- Hepatitis: Smooth, tender enlargement
- Liver abscess: Tender, systemic symptoms
- Hydatid cyst: Smooth, tropical exposure history
- Cirrhosis: Nodular, irregular liver
- Primary liver tumour: Large, firm, non-tender
- Secondary (metastatic): Hard, irregular, multiple nodules
2. Gallbladder
- Mucocele: Smooth, large gallbladder, moderately tender
- Empyema: Tender RUQ, inflamed gallbladder
- Carcinoma: Nodular, irregular, hard mass with obstructive jaundice
Courvoisier's Law: Enlarged, painless gallbladder + jaundice = malignancy, not gallstones
Epigastric Swellings
1. Stomach
- Carcinoma: Midline mass, often with gastric outlet obstruction
- Distension: Due to food, gas, or obstruction
2. Pancreas
- Pseudocyst: Smooth, cystic, may follow pancreatitis
- Pancreatic carcinoma: Irregular, hard, often deep-seated
3. Aortic Aneurysm
- Pulsatile, expansile mass
- Often asymptomatic until large or ruptured
- Urgent diagnosis via ultrasound or CT
Left Upper Quadrant (LUQ) Swellings
1. Spleen
- Moves with respiration
- Dull to percussion, cannot get above
- Common causes: portal hypertension, lymphoma, infections
2. Kidney (Upper Pole)
- Cyst, pyonephrosis, hydronephrosis
- Ballotable, resonant percussion
- Polycystic disease: Large, lobulated
Flank and Renal Masses
- Hydronephrosis: Large, smooth, tense, possible tenderness
- Renal carcinoma: Irregular, hard, may have hematuria
- Perinephric abscess: Tender, febrile, signs of infection
- Polycystic kidney disease: Bilateral, familial history
Retroperitoneal Masses
- Adrenal tumors: Usually non-palpable unless large
- Lymphoma: Smooth or nodular retroperitoneal enlargement
- Neuroblastoma (children)
Colon and Bowel Masses
Ascending Colon
- Faeces: Mobile, doughy
- Carcinoma: Hard, irregular, fixed mass
Descending Colon
- Similar findings
- Carcinoma more common than right-sided
Colon masses are often resonant on percussion and may not move with respiration
How to Clinically Differentiate Abdominal Masses
| Feature | Liver | Spleen | Kidney | Retroperitoneal | Bowel |
|---|---|---|---|---|---|
| Moves with respiration | Yes | Yes | Somewhat | No | No |
| Percussion | Dull | Dull | Resonant | Resonant | Resonant |
| Palpability | Edge below costal margin | Notched edge | Ballotable | Deep | Mobile |
| Tenderness | If infected (abscess) | Rare | If infected | Rare | Rare |
| Surface | Smooth or nodular | Smooth | Smooth or nodular | Ill-defined | Variable |
Key Investigations
Lab Tests
- FBC: Tumors, infections, anemia
- LFTs: Liver masses, gallbladder disease
- WCC: Infections (abscess, pyelonephritis)
- Tumor markers (AFP, CA 19-9, CEA)
Imaging
- Ultrasound: First-line for liver, gallbladder, kidneys
- CT scan: Best for pancreas, retroperitoneal, lymph nodes, complex cysts
- Gastroscopy: Gastric mass or outlet obstruction
- Colonoscopy: Colon mass
- Small bowel enema / Barium meal: Small bowel or colon lesions
- MRI/MRCP: Pancreaticobiliary pathologies
- Doppler: Aneurysm flow or portal vein assessment
Red Flag Features
- Rapidly enlarging mass
- Pain + jaundice
- Systemic signs: fever, weight loss, anorexia
- Hard, irregular, fixed swelling
- Associated GI bleeding or obstruction
Management Overview by Etiology
| Condition | Management |
|---|---|
| Liver abscess | Antibiotics ± drainage |
| Hydatid cyst | Albendazole + surgical excision |
| Gallbladder empyema | Urgent cholecystectomy |
| Pancreatic pseudocyst | Observation or drainage |
| Liver/pancreatic tumors | Oncological work-up |
| Colon cancer | Surgical resection + chemotherapy |
| Aortic aneurysm | Vascular referral, surgery if large |
FAQs About Upper Abdominal Swellings
How do I know if the swelling is liver or kidney?
Liver moves fully with breathing and is dull to percussion. Kidney is ballotable and resonant.
Is a painless swelling always benign?
No. Some cancers and aneurysms are painless until advanced.
Which side is the spleen on?
Left upper quadrant, under the rib cage.
Can bowel masses be felt externally?
Yes, if large or near the abdominal wall—especially in thin patients.
Is imaging always needed?
Yes, especially to differentiate solid from cystic and to assess vascular/organ involvement.
Conclusion
Localized upper abdominal swellings can originate from many sources—liver, spleen, pancreas, colon, kidneys, and beyond. Clinical assessment paired with appropriate imaging is essential for accurate diagnosis and timely management.
