2. Abdominal mass Flashcards
1
Q
Name causal conditions of abdo masses (10)
A
- Organomegaly
- Hepatomegaly
- Splenomegaly
- Enlarged kidneys
- Cysts
- Hydronephrosis
- Tumors
- Neoplasms
- Lymphoma/sarcoma
- GI tumors
- Gastric
- GI stromal tumors
- Pancreas
- Colon
- Hepatoma
- Gynecologic tumors
- Ovarian
- Uterine
- Neuroblastoma
- Other
- Pelvic organ in the Abdo
- Uterine or ectopic pregnancy
- Distended bladder
- Pancreatic pseudocyst
- Abdo aortic aneurysm
- Abdo wall masses
- Pelvic organ in the Abdo
2
Q
Name COLONIC serum tumor marker (1)
A
CEA
3
Q
Name PANCREATIC serum tumor marker (2)
A
- CEA
- CA 19-9
4
Q
Name HEPATOMA serum tumor marker (1)
A
AFP
5
Q
Name OVARIAN serum tumor marker (1)
A
CA-125
6
Q
Name GERM LINE TUMORS serum tumor marker (2)
A
- b-HCG
- AFP
7
Q
Name Signs of Symptomatic abdo aortic aneurysm (6)
A
- General diffuse Abdo, low back or flank pain
- Pulsatile paraumbilical mass
- Systolic bruit over the abdo aorta
- Tenderness over affected area on palpation
- Abdo fullness sensation
- Leg swelling
8
Q
Describe approach to patient with abdo mass (Figure)
A
9
Q
Describe HX: Abdo mass (5)
A
- A careful Hx is needed to differentiate between benign and malignant causes of abdo masses, with emphasis on personal or familial Hx of cancer and liver disease.
- Hx should also focus on separating possible etiologies based on symptoms: GI (N/V, changes in bowel habits) and GU symptoms (difficulty urinating, gross hematuria).
- Assess for Hx of weight loss, night sweats, or fevers consistent with cancer.
- The onset and course of the mass should be noted. Rapidly growing abdo masses are more concerning than stable, incidentally noted ones.
- A pulsating abdo mass is concerning for an enlarged abdo aortic aneurysm.
10
Q
Describe physical exam: Abdo mass (3)
A
- Assess the location, size, and quality of the mass (e.g., firm, soft, tender)
- Assess for concurrent signs suggestive of cirrhosis and concurrent portal venous hypertension, such as caput medusae or palmar erythema
- Identify possible surgical scars, incisional hernias, and recent postoperative seromas/hematomas
11
Q
Describe approach to abdo mass in patient with flank or back pain: Renal tumor
- Signs/Sx
- Workup
- Management
A
- Signs/Sx: Hx of hematuria, hypertension
- Workup: Kidney U/S, abdoCT
- Management: Urology referral
12
Q
Describe approach to abdo mass in patient with flank or back pain: Gastric tumor
- Signs/Sx
- Workup
- Management
A
- Signs/Sx: Hx of bloating, premature satiety, dysphagia, anorexia, melena, hematemesis, and epigastric pain
- Workup:
- Faecal occult blood (FOB) test
- double contrast radiographic examination ± endoscopy
- Management:
13
Q
Describe approach to abdo mass in patient with flank or back pain: Renal cyst
- Signs/Sx
- Workup
- Management
A
- Signs/Sx: Hx of nephrolithiasis, hematuria, renal infection, polyuria, end-stage renal disease, renal failure, hypertension, dialysis
- Workup: KidneyU/SandCT
- Management: Nephrology referral
14
Q
Describe approach to abdo mass in patient with flank or back pain: Hydronephrosis
- Signs/Sx
- Workup
- Management
A
- Signs/Sx: Hx of N/V, worsening pain with consumption of fluids, radiates to ipsilateral testes/labia, hematuria
- Workup: Kidney U/S and CT
- Management: Nephrology referral
15
Q
Describe approach to abdo mass in patient with flank or back pain: Sarcoma
- Signs/Sx
- Workup
- Management
A
- Signs/Sx:
- Rapidly enlarging mass
- Lower extremity edema
- Hx of dysphagia
- constipation
- melena
- nonspecific abdo pain
- early satiety
- sensation of fullness
- Workup: CT/MRI
- Management: Oncology referral
16
Q
Describe this abdo mass: Hepatomegaly
- Anatomical Location
- Signs/Sx
- Workup
- Management
A
- Anatomical Location: Right subcostal area
- Signs/Sx: Palpable lower border of liver, liver span > 12 cm
- Workup: Hepatic U/S and CT
- Management: See Chapter 7— Hepatology
17
Q
Describe this abdo mass: Hepatic Mass
- Anatomical Location
- Signs/Sx
- Workup
- Management
A
- Anatomical Location: Right subcostal area
- Signs/Sx:
- Jaundice
- scleral icterus
- deep palpation-induced pain
- Hx of right shoulder pain
- Decompensation of stable cirrhosis
- Workup: AFP serology, contrast CT, routine U/S for high-risk patients
- Management: General surgery referral
18
Q
Describe this abdo mass: Pancreatic tumor
- Anatomical Location
- Signs/Sx
- Workup
- Management
A
- Anatomical Location: Epigastrium, left subcostal area
- Signs/Sx:
- Nausea/vomiting
- anorexia
- weight loss
- obstructive jaundice
- Recent onset of diabetes mellitus, darkening urine, changing stool color
- Workup: CA 19-9 serology, abdo U/S and CT
- Management: General surgery referral
19
Q
Describe this abdo mass: Pancreatic pseudocyst
- Anatomical Location
- Signs/Sx
- Workup
- Management
A
- Anatomical Location: Left subcostal area
- Signs/Sx: Hx of acute or chronic pancreatitis, abdo trauma
- Workup: Abdo U/S and contrast CT
- Management: General surgery re- ferral if significant nausea and abdo pain
20
Q
Describe this abdo mass: Splenomegaly
- Anatomical Location
- Signs/Sx
- Workup
- Management
A
- Anatomical Location: Left subcostal area
- Signs/Sx: Positive Castell sign, palpable spleen
- Workup: CT scan and possible PET scan if indicated
- Management: See Chapter 11—Splenomegaly
21
Q
Describe this abdo mass: Uterine tumor
- Anatomical Location
- Signs/Sx
- Workup
- Management
A
- Anatomical Location: Suprapubic area
- Signs/Sx: Hx of abnormal vaginal bleeding ± discharge
- Workup: Endometrial biopsy
- Management: Gynecology referral
22
Q
Describe this abdo mass: Ovarian tumor
- Anatomical Location
- Signs/Sx
- Workup
- Management
A
- Anatomical Location: Suprapubic area
- Signs/Sx: Hx of abdo pain, bloating, irregular menses, or change in bowels
- Workup:
- Transvaginal U/S
- CA-125 serology
- Management: Gynecology referral
23
Q
Describe this abdo mass: Pregnancy
- Anatomical Location
- Signs/Sx
- Workup
- Management
A
- Anatomical Location: Suprapubic area
- Signs/Sx:
- Hx of fatigue, breast tenderness or enlargement, N/V, increased urination, amenorrhea
- Workup: hCG test, suprapubic U/S
- Management: See Chapter 14 — Antepartum Care
24
Q
Describe this abdo mass: Enlarged bladder
- Anatomical Location
- Signs/Sx
- Workup
- Management
A
- Anatomical Location: Suprapubic area
- Signs/Sx: Hx of urinary frequency, dysuria, change in urine appearance
- Workup: Bladder U/S
- Management: Treat cause
25
Describe this abdo mass: Neuroblastoma
* Anatomical Location
* Signs/Sx
* Workup
* Management
* Anatomical Location: Crosses the midline
* Signs/Sx: Irregular abdo mass, exclusively in pediatric patients
* Workup: CBC, ESR, AXR, and CT
* Management: Oncology referral
26
Describe investigations: Abdo mass (4)
* Routine blood work: serum hemoglobin, white cell count, platelets, electrolytes, liver enzyme tests (AST, ALT, ALP, and GGT), liver function tests (bilirubin, INR, albumin), as well as lipase (amylase is less useful in modern clinical practice).
* Every female patient within childbearing age should have a b-hCG test to exclude pregnancy.
* Routine imaging: U/S followed by CT scan of the abdo with oral as well as IV contrast, if needed.
* A tumor suspicious for malignancy should be biopsied with fine needle aspiration or core needle biopsy. A possible intraluminal mass will need to be biopsied via endoscopy. Pancreatic or biliary sources may be accessed via an ERCP
27
What biopsy to do with these pathologic conditions
28
Describe management: Abdo mass (4)
* Benign causes of abdo organomegaly such as cirrhosis and idiopathic thrombocy- topenic purpura should be referred to an internist for medical optimization.
* Malignant causes of abdo organomegaly should be referred to a general surgeon for management.
* Patients with abdo aortic aneurysms should be referred to a vascular surgeon for management.
* Renal cysts \< 3 cm in diameter require no further intervention, whereas cysts \> 3 cm carry a 5% to 10% malignancy risk and require routine follow-up with imaging (U/S or CT scans).
