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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