ABDOMINAL MASS

Michael S. Hong, MD

University of Florida Oral Exam Review

Abdominal Mass DDx

• Narrow your differential• Age• Gender• Location

• Differential guides your H&P

Pediatric Abdominal Mass

• Tumors• Wilm Tumor – (~3-4 yo) renal, flank area• Neuroblastoma – Sympathetic Nervous System, usu. Midline• Beckwith-Wiedemann – enlarged kidneys, liver• Teratoma• Rhabdomyosarcoma

• GI• Bowel obstruction• Intussusception• Pyloric stenosis

• Organomegaly

Abdominal Mass in Elderly

• GI • Sigmoid volvulus, Obstruction, Impacted stool, Colon cancer,

gastric cancer, biliary cancer, diverticulitis, portal hypertension

• GU• Urinary obstruction/retention

• Organomegaly• Spleen, liver, kidney

• Vascular• Abdominal aortic aneurysm

• Other • Hernias, pancreatic pseudocyst, metastatic disease, sarcomas,

neuroendocrine tumors, lymphomas, abscess

Abdominal mass in women

• Pregnancy• Endometriosis• Ovarian cyst/tumor• Uterine fibroids

Location of Abdominal Mass

• Flank – renal, adrenal• RLQ – appendicitis, Crohn’s, carcinoid• RUQ – biliary CA, liver adenoma,

cysts/abscess• Epigastric – gastric CA, pancreatic pseudocyst• LUQ – sigmoid volvulus, splenomegaly• LLQ – diverticulosis/litis, colon CA• Pelvic – GU/GYN

History

• OPQRST of Pain• Onset• Provoking/palliative factors• Quality of pain• Region/radiation of pain• Severity• Time

• GI: nausea, vomiting, last BM, bloody stools, clay colored stools, floating/foul smelling, caliber

• Malignancy: fever, chills, night sweats, weight loss• Bleeding/bruising – spleen and coagulation• Recent travel – infectious

History

• Mass• Timeframe, rapidity• Mobile/fixed• Local, diffuse• Tender/non-tender• Prior surgery

• Risk factors – smoking, alcohol, family history, cirrhosis

Physical exam

• Inspection – location, skin changes, size, surgical scars

• Ausculation – bowel sounds, bruits• Percussion - ascites• Palpation – peritonitis, elicit pain, pulsatility,

mobility, hardness, lymph nodes, rectal exam

Labs/Studies

• CBC, BMP, LFT, amylase, lipase, coags• KUB – free air, air-fluid levels, bowel dilatation• Ultrasound – solid or cystic, location• CT/MRI – enhanced anatomy, inflammation,

tumor, obstruction, abscess, volvulus

Example 1

• 91 year old demented man from nursing home• Intermittent abd pain, mass• No BM in last several days• Nausea, vomiting

• DDx?• Bowel obstruction, stool impaction, ileus, colon CA, rectal CA

• Next?• ROS, rectal exam• Labs: CBC, BMP• NPO, NG tube, replace fluids/electrolytes• KUB, CT scan

Example 1

• Dx: Bowel impaction• Tx: NPO, NGT,

replace lytes• Colace, senna• Enemas• Manual disimpaction

http://www.urmc.rochester.edu/radiology/education/materials/

Example 2

• 76 year old man, mass in LLQ, gradual growth• Last BM 3 days ago, Nausea, Vomiting• Weight loss• Gradually narrowing caliber stools

• DDx & Work up similar

Example 2

• Imaging: air fluid levels (obstruction)

• “Apple core” lesion in colon

• Dx: colon CA• Tx: NPO, NGT, lytes

• Staging/monitoring:• CEA• Chest CT• Colonoscopy

• Neoadjuvant therapy, Resection

• Diverting ostomyhttp://allbleedingstops.blogspot.com