Abdominal Mass 2_Hong

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ABDOMINAL MASS
Michael S. Hong, MD
University of Florida Oral Exam Review
Abdominal Mass DDx
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Narrow your differential
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Age
Gender
Location
Differential guides your H&P
Pediatric Abdominal Mass
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Tumors
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GI
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Wilm Tumor – (~3-4 yo) renal, flank area
Neuroblastoma – Sympathetic Nervous System, usu.
Midline
Beckwith-Wiedemann – enlarged kidneys, liver
Teratoma
Rhabdomyosarcoma
Bowel obstruction
Intussusception
Pyloric stenosis
Organomegaly
Abdominal Mass in Elderly
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GI
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GU
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Spleen, liver, kidney
Vascular
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Urinary obstruction/retention
Organomegaly
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Sigmoid volvulus, Obstruction, Impacted stool, Colon cancer,
gastric cancer, biliary cancer, diverticulitis, portal hypertension
Abdominal aortic aneurysm
Other
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Hernias, pancreatic pseudocyst, metastatic disease, sarcomas,
neuroendocrine tumors, lymphomas, abscess
Abdominal mass in women
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Pregnancy
Endometriosis
Ovarian cyst/tumor
Uterine fibroids
Location of Abdominal Mass
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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
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OPQRST of Pain
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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
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Mass
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Timeframe, rapidity
Mobile/fixed
Local, diffuse
Tender/non-tender
Prior surgery
Risk factors – smoking, alcohol, family history,
cirrhosis
Physical exam
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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
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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
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91 year old demented man from nursing home
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DDx?
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Intermittent abd pain, mass
No BM in last several days
Nausea, vomiting
Bowel obstruction, stool impaction, ileus, colon CA, rectal
CA
Next?
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ROS, rectal exam
Labs: CBC, BMP
NPO, NG tube, replace fluids/electrolytes
KUB, CT scan
Example 1
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Dx: Bowel impaction
Tx: NPO, NGT,
replace lytes
Colace, senna
Enemas
Manual disimpaction
http://www.urmc.rochester.edu/radiology/education/materials/
Example 2
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76 year old man, mass in LLQ, gradual growth
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Last BM 3 days ago, Nausea, Vomiting
Weight loss
Gradually narrowing caliber stools
DDx & Work up similar
Example 2
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Imaging: air fluid levels
(obstruction)
“Apple core” lesion in
colon
Dx: colon CA
Tx: NPO, NGT, lytes
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Staging/monitoring:
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CEA
Chest CT
Colonoscopy
Neoadjuvant therapy,
Resection
Diverting ostomy
http://allbleedingstops.blogspot.com

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