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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2853_Библиотеки_им_академика_М_И_Перельмана
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416 CHAPTER 9: The Abdomen, Perineum, Anus, and Rectosigmoid
B. Abdominal profiles
distended bladder
enverted umbilicus
distended bladder
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be acholic. Accurate diagnosis requires careful history, serologic testing and
liver biopsy.
Distended abdomen. The abdomen is distended by the accumulation of
uids or tissue (Fig. 9-20). Examples are obesity, gas, ascites, solid organs
enlargement (e.g., hepatomegaly, splenomegaly, polycystic kidneys, ovarian cysts, broids), obstruction of hollow organs (stomach, small and large
intestine, bladder, gallbladder), neoplasms (benign or malignant), and pregnancy. See Abdominal Distention, page 444 Tympanites, page 422 and Ascites
see below.
Ascites.
Peritoneal uid accumulates by one or more of several mechanisms:
transudation of uid from the liver surface because of portal hypertension;
obstruction of peritoneal lymphatic drainage; decreased plasma oncotic pressure; and increased peritoneal uid production with peritoneal carcinomatosis or inammation, usually infectious.
Separated rectii forming
a lens-shaped figure
Each mechanism presents with a
A. Diastasis recti
UmbilicusUmbilicus
XiphoidXipXiph XiphoidXipXip
Generalized
distention with
inverted umbilicus
from obesity
or ascites
Generalized
distention with
from ascites with
umbilical hernia
Pubisbisbisss Pubisss
Distention of
lower half
ovarian tumor,
pregnancy,
Distention of
lower third
pregnancy,
uterine fibroids,
ovarian tumor,
Scaphoid
abdomen from
malnorishment
FIG. 9-20 Visible Abdominal Signs. A. Diastasis Recti. This is abnormal separation of the abdominal rectus
muscles. It is frequently not detected when the patient is supine unless the patient’s head is raised from the pillow so that
the abdominal muscles are tensed. B. Abdominal profiles. Careful inspection from the side may give the first clue to
abnormality, directing attention to a specific region and prompting search for more signs.
Distention of
upper half
hepatomegaly,
splenomegaly,
pancreatic cyst,
acute gastric
dilatation
Abdominal Signs 417
C. Shifting dullness
Receiving
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recognizable clinical pattern. The prole of a uid-lled abdomen is a single
curve from xiphoid to pubes (Fig. 9-20B). The umbilicus is sometimes everted. Four signs characterize free uid, but ultrasonography is denitive:
1. Bulging anks produced by uid pressure on the sidewalls (Fig. 9-21B);
2. Tympany atop the abdominal curve, regardless of the patient’s position,
caused by mobile gas-lled bowel aoat on the ascitic uid (Fig. 9-21A);
3. Shifting dullness. With the patient supine, percuss the level of dullness in
the anks marking it on the skin. Then turn the patient on one side for
a minute and percuss the new level of dullness. Considerable shift indicates the presence of uid (Fig. 9-21C).
4. A uid wave is demonstrated by tapping a ank sharply with one hand
the other receiving the impulse on the opposite ank after a perceptible
time lag (Fig. 9-21D). Mesenteric fat produces a similar wave, so the fat
is blocked by having the patient or an assistant press the ulnar surface of
their hand into the midline of the abdomen. A wave passing this block is
usually caused by free uid. These signs will not detect less than 500 mL
of peritoneal uid.
Ascites—an approach to differential diagnosis. A useful physiologic approach to the differential diagnosis of ascites is based upon assessing the
likely mechanism of uid accumulation. Increased Central Venous Pressure:
Right ventricular failure, pulmonary hypertension, constrictive pericarditis,
Dullness
Dullness
FIG. 9-21 Signs of Ascites. A. Distribution of tympany. In the supine position, free fluid causes the gas-filled gut
to float, so an area of tympany forms at the top of the bulging wall. B. Bulging flanks. The free fluid pushes the flanks
outward, so they bulge toward the table or the bed. Fat in the mesentery also will cause this when the abdominal muscles
are weak. C. Shifting dullness. The dependent fluid causes an area of dullness in the lowest part which shifts to remain
lowest with changes in position of the body. D. Fluid wave. A fluid wave, elicited by tapping one side of the abdomen, is
transmitted to the receiving hand on the opposite side. The waves take perceptible time to cross the abdomen.
B. Bulging of flanksA. Distribution of tympany
Tapping
hand
hand
D. Fluid wave
418 CHAPTER 9: The Abdomen, Perineum, Anus, and Rectosigmoid
C. Distribution of dullness
with ovarian cyst
d
Umbilicus
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tricuspid valve stenosis or obstruction. Hepatic Vein Obstruction: Budd– Chiari
syndrome, thrombosis, proximal IVC obstruction or thrombosis.
of the Hepatic Sinusoids and Intrahepatic Portal Veins:
Obstruction
Cirrhosis from any
cause, primary biliary cirrhosis, amyloidosis, schistosomiasis, neoplastic inltration. Portal Vein Obstruction: Portal vein thrombosis, pylephlebitis, extrinsic compression by lymph nodes or masses in the porta hepatis.
Irritation:
cancer), tuberculosis.
Acute or chronic peritonitis, neoplastic implants (especially ovarian
Decreased Oncotic Pressure: Nephrotic syndrome, he-
Peritoneal
patocellular dysfunction, repeated large volume paracentesis, protein-losing
enteropathy, malnutrition. Thoracic Duct or Lymphatic Obstruction (Chylous
Ascites): lymphoma, metastatic neoplasm, trauma, surgical injury, trauma
to thorax or abdomen, tuberculosis, lariasis, intestinal lymphangiectasia.
Miscellaneous: Myxedema, benign ovarian adenoma with ascites and hydro-
thorax (Meigs syndrome), starvation edema, and wet beriberi (thiamine deciency and hypoproteinemia are only contributing factors).
Ovarian cyst. See Female Reproductive Tract Syndromes, Chapter 11, page
502. Large ovarian cysts lling the abdomen must be distinguished from ascites. Because they are thin walled and lled with uid they can evert the umbilicus and produce a uid wave and shifting dullness. The pelvic examination
is not diagnostic. Three signs help identify these cysts (Fig. 9-22):
1. Careful inspection of the abdominal prole reveals two curves instead of
one.
2. When a ruler is pressed transversely across the abdomen, the pulsations
of the abdominal aorta are not transmitted with free uid. If the uid is
enclosed in a tight cyst, the aortic pulsation will move the ruler (the ruler test).
3. The intestines are pushed superiorly, so the lower abdomen may be dull.
Tympaniti
Xiphoi
Dull
Pubis
A. Sagittal view of ovarian cyst
Bowel
Aorta
B. Ruler test for ovarian cyst
FIG. 9-22 Signs of Ovarian Cyst. A. Abdominal profile. The abdo minal profile shows a curve more pronounced in
the lower half. The gas-filled intestines, producing tympany, fill the superior half of the cavity, instead of floating to the top.
B. The ruler test. C. Distribution of dullness.
Abdominal Signs 419
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Obesity. Abdominal obesity results from excessive caloric intake and/or re-
distribution of adipose tissue caused by hormonal factors, especially glucocorticoids. Fat is deposited in the retroperitoneum, mesentery, organs, and
abdominal wall.
Obesity causes a uniformly rounded abdomen and increased
girth (Fig. 9-20). The umbilicus, adhering to the peritoneum, is deeply buried.
Adiposity is usually evident in other parts of the body. Men accumulate more
visceral and mesenteric fat than women. Because generalized obesity is obvious, the challenge is to determine if other causes of abdominal distention are
also present.
Pregnancy. The breasts are engorged, fetal movements and parts may be felt,
the cervix is softened, and the fetal heart should be audible. With a molar
pregnancy, there will be no signs of a fetus. A gravid uterus can resemble a
large ovarian cyst (Fig. 9-20).
Feces. A large accumulation of feces, as in megacolon, may cause distention. A history of chronic constipation and chronic laxative use are common.
Disorders of the myenteric plexus, advanced age, and use of anticholinergic
drugs are other causes. Soft deformable intraabdominal masses may be palpated; rectal examination may show stool in the vault. Tympanites is usually
absent.
Depressed abdomen—scaphoid abdomen. In extreme malnutrition the
abdominal wall sinks inward toward the vertebral column, forming a depression, bounded superiorly by the costal angle and inferiorly by the wings of
the ilia, making the shape of an ancient Greek boat, a skaphe (Fig. 9-20B). The
abdominal contents are more visible and more readily felt than normal making it easy to overestimate the size and signicance of structures that are normally not palpable.
Scars and striae. See Chapter 6, page 118.
Engorged veins. The abdominal wall veins are scarcely seen unless the skin
and subcutaneous fat are thin. Engorged veins are seen through a normal
abdominal wall. The veins distend when normal venous drainage is obstructed
increasing collateral ow. The low pressure (<30 cm H
system is easily obstructed by extrinsic compression. Slow venous ow also
increases the risk for thrombosis. Obstruction of portal venous drainage from
the abdominal viscera is most common (see Portal Hypertension, page 430).
Chest and abdominal wall collaterals also follow obstruction of the IVC distal
to the hepatic vein, iliac veins, femoral veins, superior vena cava, brachiocephalic, and subclavian veins. The pattern of distended veins on the abdomen,
chest, and extremities, together with the direction of ow, accurately predicts
the site of obstruction. Abdominal wall veins do not have valves, so ow can
be in either direction, but it is always away from the site obstruction. Above
the umbilicus ow is normally cephalad; below the navel it is caudad. The
direction of ow is the direction of most rapid relling of an empty venous
segment (Fig. 9-23). IVC obstruction causes cephalad ow in the lower abdomen (ow reversal). Portal obstruction increases normal cephalad ow in the
upper abdomen and caudad ow in the lower abdomen. SVC obstruction
O) normal venous
2
420 CHAPTER 9: The Abdomen, Perineum, Anus, and Rectosigmoid
A. B. C.
Direction of flow
D.
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Slow
FIG. 9-23 Testing Direction of Blood Flow in Superficial Veins. A. The examiner presses the blood from
the veins with his index fingers in appos ition. B. The index fingers slide apart, milking the blood f rom the inter vening
segment of vein. C. Pressure upon one end of the segment is released, observing the time of refilling from that
direction. D. Repeat the procedure, releasing the other end first. The flow of blood is in the direction of the faster flow.
causes reversed caudad ow in the upper abdomen. Very rarely, engorged
veins form a knot around the umbilicus called caput medusae.
CLINICAL OCCURRENCE: Mechanical/Traumatic: Extrinsic compression
from mass lesions (superior vena cava, IVC, and their major tributaries),
obliteration of hepatic sinusoids (portal hypertension), strictures caused
by traumatic or iatrogenic injury (surgery, instrumentation, or irradiation);
Vascular: Thrombosis caused by intravenous catheters or pacemakers (subcla-
vian, jugular, brachiocephalic, femoral), spontaneous thrombosis from congenital or acquired thrombophilia (any vein, supercial or deep).
Visible peristalsis. Normal contractions of the stomach and intestines may be
visible, under a thin abdominal wall, as slow undulations. Visible peristaltic
waves through a wall of normal thickness usually reect increased amplitude
and strength of peristalsis. They appear as oblique ridges beginning near the
LUQ and gradually moving downward and rightward. Parallel ridges may
form a ladder pattern. The waves are slow requiring several minutes of bedside observation with the eyes near the abdominal level. Abnormally powerful waves indicate obstruction. Borborygmus, intestinal rumblings heard
without a stethoscope, in conjunction with visible peristalsis and pain suggest partial or complete bowel obstruction.
Fast
Visible pulsations. The aorta can cause visible epigastric pulsation, the
amplitude increasing with wide pulse pressure, tortuous aorta, or aneurysm.
A pulsatile mass can be an aneurysm or a solid mass overlying the aorta. An
aneurysm expands laterally as well as anteroposteriorly. Ultrasonography or
CT is diagnostic.
Diastasis recti. If the two abdominal rectus muscles lack their normal midline
attachment, raising the feet reveals the separation as a midline bulge. This
may be visible or evident only on palpation (Fig. 9-20A). With the abdomen
relaxed no abnormality is seen.
Everted umbilicus. Increased intraabdominal pressure, usually from ascites,
everts the umbilicus without a true hernia.
Abdominal Signs 421
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Umbilical stula. This may discharge urine through a patent urachus, pus
from a urachal cyst or tract or an intraabdominal abscess, or feces from a connection with the colon.
Umbilical calculus. Poor hygiene leads to accumulation of dirt and desquamated epithelium in the umbilical cavity producing a hard mass often with
inammation.
Bluish umbilicus (Cullen sign). A blue coloration around the umbilicus indicates retroperitoneal bleeding.
Ecchymoses on abdomen and anks (Grey Turner sign).
First associated
with hemorrhagic pancreatitis, it is seen with retroperitoneal hemorrhage
of any cause.
The blood dissects along the deep tissue planes to the skin of
the lower abdomen, groin, and anks. The stage of hemoglobin degradation
determines the color from blue-red, to blue-purple, to green-brown.
Auscultation
Decreased or absent bowel sounds, ileus. Listen for at least 5 minutes by the
clock before accepting absent bowel sounds. Occasional weak tinkles are not
evidence of good peristalsis. High-pitched tinkling sounds and rushes may
be heard in partial obstruction. Ileus is never a primary problem, except in
intestinal pseudo-obstruction, but indicates a metabolic/toxic, inammatory,
or infectious process.
CLINICAL OCCURRENCE: Endocrine: Myxedema; Degenerative/Idiopathic:
Intestinal pseudo-obstruction; Infectious: Peritonitis; Metabolic/Toxic: Electrolyte
abnormalities: hypokalemia, hypomagnesemia, hypocalcemia; uremia; drugs:
opiates, anticholinergics;
Mechanical/Traumatic: Advanced intestinal obstruc-
tion; Neurologic: Spinal cord injury; Vascular: Mesenteric ischemia.
Increased bowel sounds. Increased peristalsis indicates bowel irritation usually resulting from luminal toxins, irritants, or early obstruction. History and
other exam ndings usually distinguishes diarrheal illness from obstruction.
Succussion splash. Air and uid in the stomach can produce audible splashes
with movement or palpation. A loud splash and distention suggests gastric
dilatation often caused by gastroparesis or outlet obstruction.
Peritoneal friction rub. A friction rub with breathing, movement, peristalsis,
or palpation indicates peritoneal inammation (Fig. 9-24). Like a pleural rub,
it sounds like two pieces of leather rubbing together.
CLINICAL OCCURRENCE: Infectious: Liver or splenic abscess, perihepa-
titis (Fitz–Hugh–Curtis syndrome); Mechanical/Traumatic: After liver biopsy;
Neoplastic: Hepatocellular carcinoma, liver metastases, peritoneal mesothe-
lioma; Vascular: Splenic infarction.
Abdominal bruits. Bruits imply arterial ow through a narrowed or tortuous
artery (generally systolic only), or large volume high to low pressure ow,
e.g. an arteriovenous malformation (both systolic and diastolic). Hepatic
arteriovenous malformations are common in HHT. Hepatocellular carcinoma
422 CHAPTER 9: The Abdomen, Perineum, Anus, and Rectosigmoid
Bruit of pancreatic carcinoma
Hepatic rubs and bruits
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Murmurs from
abdominal aorta
FIG. 9-24 Abdominal Bruits and Rubs. Green shading indicates the optimum areas for the auscultation of each sound.
Splenic friction rub
Murmur of renal artery
Femoral bruit
frequently produces a harsh arterial bruit that is either systolic or continuous
with systolic accentuation. Rarely, a venous hum is audible over a hepatic
hemangioma or in the dilated periumbilical ow associated with a patent
umbilical vein (Cruveilhier–Baumgarten syndrome). A continuous systolicdiastolic bruit can occur with a renal arteriovenous stula. Renal artery stenosis is found in approximately two-thirds of patients with systolic renal
artery bruits. These murmurs are soft, medium- or low-pitched, and most
commonly heard just above and to the left of the umbilicus (Fig. 9-24).
Percussion
Tympanitic percussion—tympanites. Tympanites indicates the presence of
free air in the abdomen from perforation or excessive gas within the bowel
from obstruction, abnormal motility, or swallowed gases. Signs of tympanites
are abdominal distention, a large area of tympany, and an abdominal prole
describing a single curve (Fig. 9-20B). Mechanical obstruction from intraluminal mass, extrinsic compression, intussusception, or volvulus commonly
produces noisy tympanites, vomiting, and colicky pain. Tympanites may
not be present with obstruction proximal to the ligament of Treitz, the gut
being too short to contain much gas and xed in the retroperitoneum. Rather,
proximal obstruction causes gastric distention with localized LUQ tympany.
With prolonged obstruction the distended stomach can drop to the pelvic
brim. Nonmechanical obstruction from decreased bowel motility, which can
be diffuse or segmental, produces silent tympanites, anorexia, and nausea,
without colic or vomiting. Both types of obstruction can occur sequentially or
together. Tympanites can occur with normal bowel sounds and no vomiting
(see Obstruction Syndromes, page 453. A small amount of intraperitoneal gas
cannot be identied by physical exam. Without peritonitis, bowel sounds can
be normal and pain absent. The amount of pain, tenderness, and guarding is
proportional to the severity of chemical peritonitis (e.g., bile or gastric acid)
or infection from perforated bowel.
CLINICAL OCCURRENCE: Intraluminal Gas—Congenital: Lactase de-
ciency, fructose malabsorption; Degenerative/Idiopathic: Intestinal pseudoobstruction, lactase deciency; Infectious: Small bowel bacterial overgrowth;
Inammatory/Immune: Megacolon from ulcerative colitis or Crohn disease;
Mechanical/Traumatic: Volvulus, ileus, endoscopic procedures, air contrast bar-
ium enema, aerophagia, carbonated beverage ingestion, bowel obstruction;
Abdominal Signs 423
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Metabolic/Toxic: Toxic megacolon, lactase deciency, articial sweeteners;
Neurologic: Ileus following spinal cord injury; Psychosocial: Factitious disorders;
Vascular: Ileus from ischemia. Pneumoperitoneum—Degenerative/Idiopathic:
Ruptured diverticulum, perforated ulcer, pneumocystoides;
Typhoid fever with perforation; ruptured diverticular abscess;
Immune:
wounds, perforating ingested foreign bodies, volvulus with perforation, postparacentesis, post-laparoscopy, post-hysterosalpingogram, peritoneal dialysis;
Neoplastic: Perforated colon cancer; Vascular: ischemic bowel with perforation.
Abdominal pain with percussion. See Rebound tenderness below.
CVA tenderness. Percussion pain and tenderness to palpation indicate
inammation of the kidney or surrounding soft tissues, e.g., pyelonephritis.
Palpation
Tenderness. Tenderness is caused by inammation of the abdominal wall,
peritoneum, or a viscus. Solid organs are tender when their capsule is
stretched. When a tender area is found during abdominal exam, repeat pal-
pation of the spot while the patient raises their head off the pillow or feet
off the table. If the tenderness is unchanged or worsens, an abdominal wall
disorder is likely. If the tenderness diminishes, an intraabdominal process is
more likely.
Rebound tenderness. The inamed peritoneum is painful with direct pres-
sure or movement, especially when two inamed surfaces slide over one
another. Because the peritoneum has somatic sensory afferents, the site of
pain is well localized.
denly withdraw them watching the patient’s face (Fig. 9-7D). Pain worsened
after withdrawal is rebound tenderness. The pain can occur at the site of pressure or remote from it. If a site of inammation is suspected, do your rst
maneuvers in the other quadrants. An alternate and less-painful method is
the use of light percussion. Rebound tenderness is a reliable sign of peritoneal
inammation. Another test for peritoneal irritation is vigorously moving the
patient’s pelvis from side to side.
stands on the oor, knees straight, rises on the toes, then drops onto the heels.
Note the location and severity of pain. This is useful when tense abdominal
muscles prevent testing rebound tenderness. A false-positive is uncommon.
Finding of jar tenderness by the heel-drop test localizes peritoneal irritation,
especially in the pelvis. Abdominal pain on running or walking is equivalent.
intermittent and variegate porphyria; Endocrine: Ectopic or tubal pregnancy;
Infectious: Pelvic inammatory disease, intraabdominal abscess; diverticulitis;
Inammatory/Immune: Peritonitis, appendicitis; cholecystitis, regional enteritis
(Crohn disease), familial Mediterranean fever, acute intermittent and variegate porphyria; Mechanical-Traumatic: Intraabdominal bleeding; Vascular:
Infarction of abdominal organs.
Perforated megacolon; Mechanical/Traumatic: Perforating abdominal
Press the ngertips gently into the abdomen, then sud-
Jar Tenderness (Markle Sign). The patient
CLINICAL OCCURRENCE: Congenital: Familial Mediterranean fever, acute
Infectious:
Inammatory/
Cutaneous hyperesthesia and allodynia. See Chapter 14, page 675. In acute
appendicitis, an area of hyperesthesia is frequently found in the RLQ preceding perforation.
424 CHAPTER 9: The Abdomen, Perineum, Anus, and Rectosigmoid
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Subcutaneous crepitus. See Chapter 6, page 118.
Voluntary muscular rigidity.
from failure to relax, a cold room or examining hands, and anxiety.
ity interferes with effective deep palpation. It is distinguished from involuntary rigidity by being abolished with suitable maneuvers (pages 398–399).
Involuntary muscular rigidity.
wall muscle spasm. Involuntary rigidity persists despite relaxing maneuvers.
Attempting a sit-up without using the arms is painful. Involuntarily rigid
muscles are not necessarily tender and must be distinguished from abdominal wall masses. Reex rigidity may be unilateral, whereas voluntary rigidity is bilaterally symmetrical. Assess symmetry by comparing muscle tension
right to left in upper and lower quadrants.
Subphrenic abscess. Pus collects under either diaphragm secondary to
suppurative lesions in the liver or spleen, or elsewhere in the abdomen,
e.g., a perforated appendix. Suspect subphrenic abscess in patients with
unexplained fever or anorexia. There may be nothing directing attention
to the region. An elevated hemidiaphragm suggested by percussion is
conrmed by X-ray. Pleural effusion, evidenced by percussion dullness,
decreased breath sounds, and decreased fremitus, can occur on the affected
side. Suspect gas under the right diaphragm when tympany is found over
the normal area of hepatic dullness. Tenderness and edema in specic locations suggests the involved subphrenic space (Fig. 9-25):
Superior Space, under the right costal margin in front of the liver, between
the sixth and tenth right intercostal spaces anteriorly; Right Anterior Inferior
Space, below the right anterior costal margin behind the liver; Left Anterior
Superior Space, under the left costal margin anteriorly, between the sixth and
tenth left interspaces in the midclavicular line; Left Anterior Inferior Space,
under the left costal margin in the mid axillary line; and Left Posterior Inferior
Space, over the left twelfth rib.
Increased abdominal wall muscle tone results
The rigid-
Peritoneal irritation causes reex abdominal
Right Anterior
Abdominal masses. See Abdominal Masses, page 455. If sufciently large or
close to the abdominal wall, masses produce resistance to light palpation.
Light palpation determines only the presence of a mass and its location. Note
whether the shape and location correspond to abdominal muscles or resembles a viscus. Describe the mass by location, size, shape, consistency, surface,
tenderness, and mobility. Not all masses are intraabdominal. Intramural
masses remain palpable when the abdominal muscles are tensed; intraabdominal masses become less distinct (Fig. 9-26).
frequently mistaken for an intraabdominal mass.
Shallow abdominal cavity. Enlarged paraaortic and/or mesenteric lymph
nodes (retroperitoneal lymphadenopathy) can ll the retroperitoneal space.
The nodes are covered with fascia and abdominal viscera, making the oor of
the abdominal cavity seem more accessible than normal. The abdominal cav-
ity seems shallower than normal, but without denite masses, discrete nodes
not being felt. (Fig. 9-27). Retroperitoneal nodes are best visualized by CT or
MRI. Lymphoma, metastatic germ cell tumors, and granulomatous diseases
DDX: Rectus hematoma is
Abdominal Signs 425
Right
Right sagittal section
Right posterio
Left
Left sagittal section
Superior space
B. Palpation of mass in abdominal wall
Tense
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Liver
Inferior space
Kidney
Right anterior
r
superior space
Right anterior
inferior space
Colon
Left anterior
Liver
Left anterior
inferior space
Stomach
Left posterior
inferior space
FIG. 9-25 Locations of Subphrenic Abscesses. The loci are in the right midclavicular line, behind the costal margin,
and the LUQ. Posteriorly, the region of the right kidney should be examined.
abdominal
muscles
A. Palpation of intra-abdominal muscles
Tense
abdominal
muscles
FIG. 9-26 Distinguishing Between Intramural and Intraabdominal Masses. Palpate the mass while the
patient raises his head from the pillow. When the abdominal muscles tense, the intraabdominal mass moves away from the
palpating hand, whereas the intramural mass remains accessible.
are most common. The massively enlarged kidneys of polycystic kidney disease also produce this nding.
Nodular umbilicus (Sister Mary Joseph nodule). Intraabdominal carcinoma,
especially gastric cancer, can metastasize to the navel.
Pulseless femoral artery (Leriche syndrome). Always palpate the femoral
arteries during abdominal exam. See Chapter 8, page 375 for further discussion.
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