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456 CHAPTER 9: The Abdomen, Perineum, Anus, and Rectosigmoid
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RUQ Mass. The liver, gallbladder, and right kidney are most likely to present
as RUQ masses. Less common are pancreatic pseudocysts and colon masses.
Enlarged liver, hepatomegaly.
The liver lls the anterior RUQ behind the
ribs. The left lobe extends leftward to the midclavicular line, though it is rarely palpable. The liver has convex and concave surfaces; the concave inferior
surface tips backward and downward. The relatively heavy liver is suspended from the diaphragm by the coronal ligaments (Fig. 9-35). The diaphragm’s
support is augmented by the hilar vessels and the combination of negative
intrathoracic pressure and positive intraabdominal pressure produced by the
abdominal wall muscles. There are two axes of liver rotation, a transverse
axis near the attachment of the coronary ligaments and an anteroposterior
axis near the hilum, to the left of the center of mass. Downward rotation
through the transverse axis presents more of the anterior surface below the
costal margin (Fig. 9-35B). Downward rotation about the anteroposterior axis
results in a tongue of liver appearing in the right ank (Fig. 9-35A). Rotation
is expected with any condition that lowers the dome of the diaphragm, decreases the normal amount of abdominal fat, or decreases abdominal muscle
tone.
Many normal livers are readily palpable just below the costal margin.
The edge roughly parallels the costal margin (Fig. 9-35A). Liver size is estimated by measuring from the upper border of hepatic dullness to a lower
border determined by palpation or percussion, but estimates of liver size
based on percussion are notoriously inaccurate. Many clinical impressions of
hepatomegaly are not conrmed with imaging or autopsy because the rotations of the normal liver are not appreciated. The surface should be examined
for consistency and nodularity. Tenderness can be elicited by direct palpation
or by st percussion. Percussion tenderness occurs in acute cholecystitis and
FIG. 9-35 Rotations of the Normal-Sized Liver Making it Palpable Beneath the Costal Margin. The liver
is suspended by its coronary ligaments and is fixed to the prevertebral fascia by its hilar blood vessels behind the right costal
margin. The diaphragm could not hold a 1500-g liver if not assisted by the negative intrapleural pressure above it, and the
positive pressure of abdominal contents, below. Depression of the diaphragm or relaxation of the intraabdominal pressure
permits the normal liver to fall beneath the costal margin and become palpable (ptosis). With the diaphragm fixed, the liver
may rotate on one or two axes to become palpable. Depression of the diaphragm increases the amount of palpable surface
permitted by rotation. A. The normal-sized liver can rotate on an anteroposterior axis near its left side. With
this counterclockwise rotation the lower border appears below the costal margin, forming an angle with the costal margin. B.
The normal-sized liver can rotate on a transverse axis. The liver edge presents below and approx imately parallel to
the costal margin. This is distinguished from liver enlargement only by the inward curve of the anterior surface.
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hepatitis. Palpate over the liver for friction rubs and auscultate for bruits.
The coincidence of these two signs indicates a high probability of hepatic
carcinoma.
CLINICAL OCCURRENCE: Congenital: Polycystic kidney disease, glycogen
storage disease, lipopolysaccharidases, hemochromatosis;
abscess (bacterial or amebiasis), echinococcal cyst, viral hepatitis, schistosomiasis, leishmaniasis; Inammatory/Immune: Amyloidosis; Mechanical/Traumatic:
Hematoma, CHF, tricuspid insufciency, pulmonary hypertension, cor
pulmonale, constrictive pericarditis, hepatic vein thrombosis; Metabolic/Toxic:
Steatosis, rickets; Neoplastic: Hepatocellular carcinoma, metastatic carcinoma
(especially colon, pancreas, lung, breast), islet cell carcinoma and carcinoid,
biliary carcinoma, histiocytosis syndromes, leukemic inltration, lymphoma,
myelobrosis/extramedullary hematopoiesis; Vascular: Hemangioma, infarc-
tion, hematoma.
Pulsatile liver. The liver may directly transmit the aortic pulse wave. Alternatively, retrograde ow from the central veins during ventricular systole can
expand the liver volume. Expansile pulsation is demonstrated by placing the
hands on opposite sides of the liver and observing that the surfaces move
apart in systole. Tricuspid insufciency is the usual cause.
Infectious: Liver
Nonalcoholic fatty liver disease (NAFLD); nonalcoholic steatohepatitis
(NASH).
glyceridemia, and with older age, initially without inammation. Inammation (NASH) leads to brosis and cirrhosis in some patients. Both conditions
are asymptomatic until cirrhosis, portal hypertension, and hepatic insufciency
appear. Transaminases may be elevated during this asymptomatic period.
Hemochromatosis. Homozygous or compound heterozygous recessive muta-
tions prevent suppression of hepatic hepcidin release resulting in excessive
enterocyte absorption of iron. Parenchymal iron accumulation causing tissue
injury results in multiple organ’s dysfunction, including liver cirrhosis, heart
failure, diabetes mellitus from islet cell damage, arthritis, pituitary insufciency, and melanism. Phenotypic expression is much higher in men. Women
are protected during childbearing years by regular menstrual blood loss. Iron
accumulation is asymptomatic. Skin color may be bronze, blue-gray, brown,
or black, accentuated in the exor folds, the nipples, recent scars, and in parts
exposed to the sun. The pigment is melanin, although hemosiderin is also
increased. Skin color change may antedate hepatic cirrhosis and diabetes by
several years. When major organ damage occurs, lassitude, weight loss, joint
pain, abdominal pain, and loss of libido may be seen. Signs are diffuse bronze
skin pigmentation (melanin), hepatomegaly, splenomegaly, spider angiomas,
loss of body hair, edema, ascites, peripheral neuropathy, arthropathy, and
testicular atrophy. Early diagnosis and therapeutic phlebotomy avoids organ
damage. Iron overload resulting from hypertransfusion in refractory anemias
produces a similar syndrome.
Enlarged tender gallbladder. See Cholecystitis, page 437.
Enlarged nontender gallbladder. Common bile duct obstruction leads to
progressive gallbladder distention. A palpable nontender gallbladder is
Fat accumulates in hepatocytes in type 2 diabetes, obesity, hypertri-
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caused by distention with stones, acalculous cholecystitis, and gallbladder hydrops in which mucous cells continue to secrete despite cystic duct
obstruction. Chronic cystic duct obstruction usually produces a contracted
gallbladder. A palpable nontender gallbladder (Courvoisier sign) implies
gallbladder dilatation due to carcinoma in the head of the pancreas
rather than a common duct stone since stones cause chronic cholecystitis and a scarred contracted gallbladder wall. There are many exceptions.
Carcinoma of the gallbladder produces a hard, irregular, moderately tender mass.
Enlarged kidney.
are contained posteriorly by the psoas and the twelfth rib while the liver
(right) or spleen (left) prevent extension superiorly (see Fig. 9-2, page 395
for the anatomic relationships of the kidneys). Therefore, enlarging kidney
push forward and downward into a position similar to an enlarged spleen
or liver, only deeper. The kidney contour is always rounded in contrast to
the relatively sharp liver and spleen edges. The left kidney is differentiated
from the spleen by its deep location and lobulated surface which must
not be mistaken for the splenic notch. Since the kidneys are in the retroperitoneum they do not move with deep inspiration like the spleen and
liver. In thin persons, the lower pole of the right kidney may be palpable
whereas the left is not. Because their shapes are so dissimilar, there is usually no difculty distinguishing kidney from liver. Rarely, a protruding
renal mass may be confused with hydrops of the gallbladder or pancreatic
pseudocyst.
CLINICAL OCCURRENCE: Congenital: Polycystic kidney disease, horseshoe
kidney, compensatory hypertrophy opposite absent kidney; Degenerative/
Idiopathic: Cysts; Inammatory/Immune: Amyloidosis; Mechanical/Traumatic:
Hydronephrosis, hematoma; Neoplastic: Renal cell carcinoma and renal sarcoma, transitional cell carcinoma of renal pelvis and ureter.
Ptotic and transplanted kidney. The surrounding fascia holds the kidneys loosely within the superior retroperitoneal space; inferior displacement is not rare, even into the pelvis. Size and shape allow identification,
but only if a displaced kidney is considered. Transplanted kidneys are
placed in the pelvis where they are easily palpable above the inguinal
ligament.
Epigastric masses. Smooth nontender epigastric masses suggest enlarge-
ment or distention of normal organs; tenderness implies infection, hemorrhage, or inammation. Irregular masses suggest neoplasm or a polycystic
The abdominal prole offers a clue to diagnosis (see Fig. 9-20, page
organ.
416). Acute gastric dilatation produces visible distention in the epigastrium
and LUQ. A pulsatile mass is an aortic aneurysm until proven otherwise. In
the absence of acute illness, a smooth epigastric mass suggests a pancreatic
cyst or pseudocyst. Enlargement of the left lobe of the liver also presents in
the epigastrium. Liver and retroperitoneal masses are immobile on palpation, but the liver moves with respirations. Infections and neoplasms produce masses in the omentum, stomach, pancreas, left lobe of the liver, and
transverse colon. A polycystic or horseshoe kidney sometimes presents as a
midline epigastric mass. Massive periaortic lymph node enlargement may
The right kidney lies lower than the left. The kidneys
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be palpable. Ultrasonography or CT is usually necessary to delineate the
involved structure(s).
LUQ mass. A LUQ mass most likely arises from the spleen, kidney, left lobe
of the liver, or colon.
Splenomegaly.
splenic notch on the medial edge near the lower pole. Enlargement displaces
the lower pole downward from behind the thoracic cage and along its oblique
axis toward the left iliac fossa. The lower pole may reach the pelvis and rarely
crosses the midline.
soft spleen with blunted edges while chronic disorders cause a rm or hard
spleen with sharp edges. Tenderness indicates peritoneal inammation from
infection or infarction. Although uncommon, the spleen can rupture from
over-vigorous palpation, most often in infectious mononucleosis.
enlarged spleen and left kidney may have the same general shape, but the
kidney is deeper, rounded posteriorly, and never has a distinct edge. Kidney
lobulations must not be mistaken for the splenic notch. Ultrasonography or
CT is denitive.
CLINICAL OCCURRENCE: Congenital: Thalassemia minor and major,
lipopolysaccharidases (Gaucher disease, Niemann–Pick disease); Infectious:
Acute and chronic malaria, typhoid fever, SBE, abscess, schistosomiasis, congenital syphilis, leishmaniasis; Inammatory/Immune: Hemolytic
anemia, SLE, RA, pernicious anemia, amyloidosis; Mechanical/Traumatic:
Chronic CHF, portal hypertension, hematoma; Metabolic/Toxic: Pernicious
anemia; Neoplastic: ALL, lymphoma, CML, CLL; Vascular: Infarcts, vasculitis, hematoma.
Enlarged kidney. See page 458.
RLQ masses. The normal cecum is felt as an indistinct doughy slightly tender mass. Sometimes it is uctuant. Tuberculosis, pericecal or appendiceal
abscess, Crohn disease, and carcinoma produce rm masses in the cecum and
terminal ileum.
LLQ masses. Irregular plastic fecal masses in the sigmoid are occasionally mistaken for neoplasm. Fecal masses move or disappear in a couple
of days. A spastic sigmoid colon is felt as a cord about the diameter of the
little nger, lying vertically about 5 cm medial to the left anterior superior iliac spine; the cord can be rolled under the ngers and is slightly or
moderately tender. A tender LLQ mass suggests diverticular phlegmon or
abscess.
The enlarged spleen retains its characteristic shape with the
Many acute infections produce a moderately enlarged
DDX: The
Suprapubic and pelvic masses. Suprapubic masses most often arise within
the pelvis. Pelvic and rectal exam is required for a complete description. Pelvic
masses arise from the colon, the female or male pelvic organs, and rarely from
accumulation of neoplastic or inammatory debris on the pelvic oor.
Pregnancy. All pubescent and post-pubescent women prior to menopause
who present with a pelvic or suprapubic mass are assumed to be pregnant
until proven otherwise.
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Distended urinary bladder. A chronically obstructed urinary bladder may
reach the umbilicus, usually in the midline.
urinary symptoms or complain of incontinence (because of overow). The
mass is dull to percussion, uctuant, painless, and disappears with catheterization. It can be mistaken for a neoplasm when a diverticulum disrupts its
symmetry. It must be distinguished from ovarian cyst and pregnancy in the
female.
Ovarian cyst. See 418.
Pelvic abscess.
gans, perforation of pelvic or abdominal organs, dissection of abdominal wall
infections, and lymphatic extension of regional infections.
specic anatomy of the male and female pelvis is necessary for interpreting
the exam. In the male, a tender, rounded mass, felt through the anterior rectal
wall, superior to the prostate gland, is likely to be a pelvic abscess in the rectovesical pouch. Similarly, in the female, a mass felt through the anterior rectal
wall superior to the cervix uteri is probably an abscess in the rectouterine
pouch. These abscesses result from perforation of the appendix or a colonic
diverticulum, salpingitis, or prostatitis.
Other abdominal masses. The masses previously described involve tissues
generally localized to a specic region. However, a mass can form anywhere
in the gut. Volvulus (page 434) is usually in the sigmoid colon or the cecum
but may occur elsewhere. Intussusception (page 453) occurs primarily in
children. An abscess can present as a mass in any part of the abdomen.
Abscess should be suspected when a mass is palpated in a region normally
devoid of solid organs. Colon cancer and inammatory masses associated
with Crohn disease may be found virtually anywhere in the abdomen or
pelvis. Except for intussusception, these conditions so not have distinctive
physical ndings.
Pelvic abscesses result from suppurative disease of pelvic or-
The patient may have minimal
Knowledge of the
Abdominal, Inguinal, and Other Hernias
Strangulated hernia. Occlusion of venous return from herniating gut or
omentum produces swelling and edema preventing reduction. The gradual
increase in pressure ultimately prevents capillary and arterial ow; gangrene
and perforation may quickly ensue. Pinching and strangulation of only a partial circumference of the gut wall produces a Richter hernia. Most commonly a
previously recognized hernia presents as a painful mass producing intestinal
obstruction. Strangulated bowel is painful, feels rm, but is usually not tender. Forceful attempts at reduction may result in rupture of strangulated gut
or reduction en masse, where the hernia sac accompanies the loop of bowel
without relieving the strangulation.
Incisional hernia. Palpate for a defect in the abdominal wall underlying an
operative scar. Have the patient perform a Valsalva maneuver or raise their
head off the pillow. Herniation occurs adjacent to the scar (Fig. 9-36).
Epigastric hernia (fatty hernia of the linea alba). Preperitoneal fat protrudes
between the bers of the linea alba, usually without a peritoneal sac. The
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FIG. 9-36 Abdominal Wall Hernia. This hernia is not evident when the patient is at rest on the exam table. Straining
forces the abdominal contents into the hernia as the abdominal wall muscles contract.
patient can have midline pain in the epigastrium. To identify the hernia, have
the patient stand while running a nger down the midline looking for a small
nodule which is occasionally reducible.
Umbilical hernia. There is a defect in the abdominal fascia where the umbili-
cal vessels and urachus exit the abdomen into the umbilical cord. A congenital hernia protrudes through the umbilical scar and has a complete brous
collar continuous with the linea alba. The adult hernia is periumbilical, the
collar is absent, and the upper part of the hernia is covered only by skin.
navel may protrude when intraabdominal pressure is increased by standing
or Valsalva. These hernias are soft except when chronic inammation has
caused brosis. Umbilical hernias are very common in infants and tend to
resolve spontaneously by 4 years of age. The adult type frequently develops
during pregnancy, in long-standing ascites, or when intrathoracic pressure
is repeatedly increased as in asthma, chronic bronchitis, and bronchiectasis.
The
Inguinal hernias
Zieman inguinal examination. This examination detects direct and indirect
inguinal hernias and hernias into the femoral triangle, so it is effective in
women and men. The patient stands to the examiners left side. Placing the
palm of the right hand against the right lower abdomen spread the ngers
slightly so the long nger lies along the inguinal ligament with the ngertip
in the external inguinal ring (Chapter 12, Fig. 12-5B, page 512). The index nger is over the internal inguinal ring, and the ring nger lies over the femoral
canal and the fascial opening for the saphenous vein. The patient takes a deep
breath, holds it, and bears down as if to have a bowel movement. A hernia in
any of the three sites is felt as either a gliding motion of the walls of the empty
sac or as a protrusion into the sac. When the internal ring is closed by the
index nger, any herniating mass cannot be an indirect inguinal hernia. The
examination on the left is the mirror image of the right using the left hand.
Indirect inguinal hernia.
point of the inguinal ligament. In men, the spermatic cord emerges from
the abdominal cavity through this ring, runs medially in the canal, exiting
The internal inguinal ring lies just above the mid-
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the subcutaneous external ring just lateral to the pubis, then drops over
the brim of the bony pelvis into the scrotum. Inguinal hernias follow the
course of the cord; they may extend only a small distance into the canal or
descend into the scrotum. In the female, the round ligament corresponds to
the spermatic cord and the hernia follows a similar course. In either sex, a
small, indirect inguinal hernia may produce a bulge over the midpoint of
the inguinal ligament at the abdominal (internal) inguinal ring (Fig. 9-37).
To palpate the male inguinal canal, place the index ngertip at the most
dependent part of the scrotum then gently lift it into the subcutaneous external inguinal ring by invaginating scrotum (Fig. 12-5A). When the patient
coughs or strains a tap from the hernia sac may be felt on the ngertip. A
larger hernia may feel like a mass in the canal. In the female, palpation of
the inguinal canal is usually unsatisfactory.
Direct inguinal hernia.
canal is termed direct. The site of the weakness is Hesselbach triangle, bounded
by the inferior epigastric artery, the lateral border of the rectus muscle and
the inguinal ligament, Thus, it lies nearly directly behind the subcutaneous
(external) inguinal ring. A bulge is produced close to the pubic tubercle, just
above the inguinal ligament, medial to the site of an indirect hernia (Fig. 9-37).
When examining the inguinal canal, coughing or straining produces an impulse on the pad not the tip of the nger. Direct hernias usually occur in men,
are always acquired, and seldom cause pain.
Femoral hernia. The femoral nerve, artery, and vein lie lateral and just infe-
rior to the midpoint of the inguinal ligament. Immediately medial to the vein
is the femoral canal, a continuation of the femoral sheath, through which a
hernia may bulge with increased intraabdominal pressure (Fig. 9-37).
femoral hernias become irreducible and may push upward in front of the
inguinal ligament where they can be confused with inguinal hernias. Palpating the hernia sac neck just lateral to and below the pubic tubercle conrms
a femoral hernia. The neck of an inguinal hernia sac is above the inguinal
ligament.
Obturator hernia.
in the pelvis producing a fullness or mass in the femoral triangle. The fullness
is not sharply dened because the sac is covered by the pectineus muscle.
This rare lesion occurs almost always in older emaciated women with a history of weight loss. The hernia is rarely diagnosed before it has caused intes-
tinal obstruction. The thigh on the affected side is usually held in semiexion.
Any hip motion produces pain. When the genicular branch of the obturator
nerve is compressed, the pain extends down the medial thigh to the knee
(Romberg–Howship sign). Palpation through the rectum or vagina may reveal
a soft tender mass in the region of the obturator foramen. Obturator hernia
must be distinguished from the far more common femoral hernia. When only
a portion of the bowel circumference is strangulated (Richter hernia) obstruction does not occur. Pain may occur late, only after perforation or sepsis has
occurred.
A hernia through the posterior wall of the inguinal
Large
A peritoneal sac protrudes through the obturator foramen
Spigelian hernia. A peritoneal sac with considerable extraperitoneal fat pen-
etrates the linea semilunaris to lie within the abdominal wall covered only by
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FIG. 9-37 Hernias in the Inguinal Region. Inguinal hernias. The inguinal ligament stretches from the anterior
superior spine of the ilium to the pubic tubercle. The flattened tube of the inguinal canal lies just above and parallel to it,
between the superficial and deep layers of abdominal muscles. The lateral end of the canal opens posteriorly into the abdominal cavity through the abdominal inguinal ring (internal ring). The internal ring is not palpable, but it is just above the midpoint
of the inguinal ligament. The medial end of the canal opens anteriorly into the subcutaneous tissue through the subcutaneous
inguinal ring (external ring). In the male, this is where the spermatic cord emerges from the abdominal muscles. A hernia is
indirect when it enters the canal from the abdominal cavity through the abdominal inguinal ring; a hernia entering medial
to this ring is direct. In small hernias, the relation of the bulge to the midpoint of the inguinal ligament is diagnostic of direct
or indirect. If the hernia is large, palpating the inguinal canal through the scrotum may determine the entrance site into the
canal. The direct hernia is as an anterior bulging of the posterior wall of the inguinal canal. Femoral hernia. The femoral
artery and vein emerge from the abdomen beneath the midpoint of the inguinal ligament, where the artery is palpable. The
impalp able femoral ve in is immediate ly medial to the artery and the femoral cana l lies medial to t he vein ~2 cm medial to the
pulsating artery. A bulge in the region of the femoral canal on coughing or straining indicates a femoral hernia. A femoral hernia
protruding upward in front of the inguinal ligament may be confused with an inguinal hernia. Careful palpation demonstrates
that the inguinal canal is empty.
skin, subcutaneous fat, and aponeurosis of the abdominal external oblique
muscle. It is usually asymptomatic until it strangulates. There is a tender ab-
dominal wall mass 3–5 cm above the inguinal ligament. Examination is by
inspection and palpation while the patient stands.
Other inguinal masses. Additional causes of a groin masses are lymph
nodes, varix, aneurysms, lipoma, ectopic testis, ectopic spleen, and inguinal
endometriosis.
Lymphadenopathy. Inammation, infection, or neoplastic involvement of
lymph nodes causes enlargement with or without tenderness. Inamma-
tion and uctuant lymph node swelling near the femoral vessels below the
inguinal ligament is a so-called bubo occurring in chancroid, syphilis, and
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lymphogranuloma venereum. Neoplastic nodes are nontender and rubbery
or hard. See Chapter 5, page 83.
Saphenous vein varix. A varix of the saphenous vein is seen as a bulge just below the femoral canal. The varix lls with standing and empties when supine;
a distinctive thrill may be felt.
Perineal, Anal, and Rectal Syndromes
Brief intense perineal pain—proctalgia fugax. The cause is unknown, but
men are more often affected than women. The patient awakens from sleep
with intense, poorly localized pain in the perineum or rectum. The paroxysm
reaches an agonizing maximum in 1–2 minutes, and then subsides rapidly
and completely in about 5 minutes. During the pain, the patient may walk
about or attempt defecation. Relief has been reported from pressure on the
perineum, nitroglycerin, or an enema of warm water. Occasionally, the paroxysm is initiated by straining at stool, prolonged sitting on a hard surface,
or ejaculation.
Fecal incontinence. See page 412.
Occult GI Blood Loss
Testing for occult blood. The bedside stool guaiac test should only be used when
recent GI bleeding is suspected by history or examining a stool. False-positive
guaiac results lead to misdirected evaluations. Occult blood screening for
colorectal neoplasms is best done with immunochemical methods which are
quantitative and far superior to guaiac testing. Bleeding from any site in the
alimentary or the upper respiratory tracts can give a positive test for blood
without discoloring the stool. But only guaiac testing (not immunochemical)
detects upper GI bleeding (digested blood). The source of occult blood loss is
sought by endoscopy.
GI bleeding associated with skin lesions. In some patients, GI blood loss is
associated with skin lesions having their counterparts in the GI tract.
Peutz–Jeghers syndrome. See Chapter 7, page 223 and Fig. 7-59 page 222.
HHT (Rendu–Osler–Weber disease). Telangiectases on the face, nasal or buc-
cal mucosa, and extremities suggest similar lesions in the GI tract.
Blue rubber–Bleb Nevus syndrome. Cutaneous cavernous hemangiomas,
especially on the trunk or extremities, suggest similar lesions in the small
intestine.
Ehlers–Danlos syndrome. Common signs are hyper elastic skin, hyper exible joints, petechiae, and fragile skin.
Pseudoxanthoma elastic. See Chapter 6, page 151.
Neurobromatosis (von Recklinghausen disease). See Chapter 6, page 151.
Amyloidosis (primary or secondary). See Chapter 5, page 87.
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Malignant atrophic papulosis (Degos disease). This is a vasculitis of the
skin and mucosa. Small, red papules on the skin become umbilicated, with
porcelain-white depressed centers and dry scale. The border disappears,
leaving a white patch. Patients may have acute abdominal pain with vomiting and bleeding which can progress to gangrene and peritonitis.
Schölein–Henoch purpura. See Chapter 8, Vasculitis, page 360.
Drugs. Aspirin and other NSAIDs produce erosive lesions which can bleed
anywhere in the GI tract. Warfarin is associated with large bruises and bleeding in the GI tract.
Scurvy. See Chapter 6, page 152.
Kaposi sarcoma. Endemic Kaposi sarcoma presents as dark-blue nodules and
plaques usually on the feet. HIV-associated Kaposi sarcoma frequently involves the mucous membranes of the mouth and GI and genitourinary tracts.
Mastocytosis. See Chapter 6, page 117.
ADDITIONAL READING
William Silen. Cope’s Early Diagnosis of the Acute Abdomen. 22nd ed. New York,
NY: Oxford University Press; 2010.
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