Approach To Abdominal Mass Flashcards
What age group is most commonly affected by cystic mesoblastic nephroma?
• <6 months
What age group is most commonly affected by hepatoblastoma?
6-18 months
What age group is most commonly affected by neuroblastoma?
1-2 years
What age group is most commonly affected by nephroblastoma?
2-3 years (rare <6 months or >8 years)
What age group is most commonly affected by rhabdomyosarcoma?
3-5 years
What age group is most commonly affected by fibrolamellar hepatocellular carcinoma?
Teenagers
What antenatal condition requires follow-up postnatal ultrasound?
Hydronephrosis
When should postnatal ultrasound be performed for hydronephrosis?
About 2 weeks postnatally
Why should ultrasound be deferred if there is physiological oliguria in the first 72 hours after birth?
• It might cause a false negative follow-up renal ultrasound
What condition should be considered with oligohydramnios?
Possible renal pathology
What condition should be considered with polyhydramnios?
Possible bowel obstruction
What are the features of sepsis to look for in a general examination of a child with an abdominal mass?
Signs of infection: fever, tachycardia, hypotension
What are the signs of bowel obstruction in a child with an abdominal mass?
• Visible stomach bubble/bowel loops
• Generalized abdominal distension
• Cramp-like, coming-and-going pain
What signs suggest urinary tract obstruction in a child with an abdominal mass?
Palpable bladder
What constitutional non-specific symptoms of malignancy should be looked for?
• Weight loss
• Lymphadenopathy
• Pallor
• Lethargy
What skin signs might suggest neuroblastoma metastases?
• “Blueberry muffin” spots
• “Panda bear eyes”
What skin signs might suggest Peutz-Jegher’s syndrome?
Mucosal pigmentation (peri-oral & axillary freckling)
What condition may be suggested by Peutz-Jegher’s syndrome skin signs?
Intestinal hamartomatous polyps, potentially leading to intussusception
What should be considered with pyrexia in a child with an abdominal mass?
• Infection (if high-grade)
• Hematological malignancy (if low-grade)
How common is hypertension in children with nephroblastoma and neuroblastoma?
Hypertension may occur in up to 80% of children with nephroblastoma
• More common with neuroblastoma, and can cause a hypertensive crisis
What are the important characteristics to describe a mass in children?
• Size
• Shape and contour (smooth, round, septated, irregular edges, or nodular surface)
• Consistency (cystic, solid, pulsatile, conformable, or succussion splash suggesting gastric outlet obstruction)
• Mobility (tethered to organ/retroperitoneum, or free-floating like an auto-amputated ovarian cyst or small bowel duplication cyst)
• Anatomical relations (e.g., fixed central solid mass suggests neuroblastoma, lateral mass suggests nephroblastoma)
How can the presence of a nasogastric tube or urinary catheter help assess a mass?
They may relieve distension or make the mass easier to palpate
When should a digital rectal exam be considered?
• If there is a pelvic mass or symptoms of constipation/bowel obstruction
• To exclude presacral masses (e.g., teratoma, myelomeningocele, dermoid cyst)
What should be checked during a perineal exam?
• Normal anal position
• Bulging imperforate hymen
• Presacral mass
What should be checked on a urine dipstick for abdominal/flank and pelvic masses?
• Hematuria (suggestive of nephroblastoma)
• Urinary tract infection (UTI) screening
• Proteinuria (suggestive of renal disease)
What laboratory tests should be performed for a child with an abdominal mass?
• Full blood count (look for anemia, low platelets, high white blood cell count, or high platelet count)
• Baseline serum urea, creatinine, & electrolytes (especially if vomiting or signs of bowel obstruction)
• Liver function tests (if jaundice or pancreatic pathology suspected)
When are tumor markers useful in children with abdominal masses?
After imaging, certain tumor markers can help establish the diagnosis and track treatment response
What are non-specific markers of increased cell turnover that suggest malignancy?
• Ferritin
• Uric acid
• LDH
What tumor markers are useful for liver tumors and teratomas?
• Alpha-fetoprotein (AFP)
• Beta-HCG
What markers are useful for adrenal neuroblastoma or pheochromocytoma?
Urinary catecholamines (homovanillic acid, vanillylmandelic acid)
What tumor marker is useful for ovarian tumors?
Beta-HCG
What tumor markers are useful for testicular tumors?
• AFP
• LDH
What is the gold standard for the initial investigation of a mass in children?
Ultrasound
What is the significance of the “tram-track” appearance in ultrasound?
Pathognomonic for a duplication cyst (hyperechoic mucosa outlining both sides of the muscularis wall)
How can Doppler imaging be useful in ultrasound for abdominal masses?
Helps assess the degree of vascular invasion (e.g., inferior vena cava patency in nephroblastoma)
When is abdominal x-ray useful in children with abdominal masses?
• If there is clinical suspicion of bowel obstruction (e.g., worm bolus obstruction, level of bowel obstruction)
• To look for free air indicating the need for urgent surgical exploration
What conditions can be identified on abdominal x-ray?
• Calcification in teratoma or neuroblastoma
• Meconium pseudocyst
• Renal or biliary stones secondary to urinary tract or biliary tree obstruction
When is MRI used for abdominal masses in children
For further anatomical definition of a mass, especially to plan surgical resectability
Why is abdominal CT scan largely avoided in children?
Due to the risks of ionizing radiation
When is CT scan used in the assessment of abdominal masses?
To assess for pulmonary metastatic disease
When is a biopsy performed in children with abdominal masses?
• After radiological definition of the mass
• Biopsy may be image-guided (e.g., ultrasound)
• Fine-needle aspiration, trucut/core-needle biopsy, or open/laparoscopic-assisted surgical biopsy may be required
When is a bone marrow biopsy performed in children with abdominal masses?
To stage the tumor
When should a referral be made for a possible malignancy?
• Urgently, to a tertiary center for further special investigation without delay
• Always discuss with the referral center
