Sie sind auf Seite 1von 49

 Abdominal mass in neonates

 Abdominal mass in infants\children


 Abdominal mass in adults
 History
 Physical examination
 investigation
 An abdominal mass is an abnormal growth that
occurs in the abdomen. An abdominal mass causes
visible swelling and may change the shape of the
abdomen. A person with an abdominal mass may
notice weight gain and symptoms such as
abdominal discomfort, pain, and bloating.
 The patient’s age is among the most important
factors that help narrow the potential etiologies of an
abdominal mass since its causes differ between
neonates and infants /children.
 Abdominal masses in neonates are most often
benign and of genitourinary origin. Malignant
abdominal masses are more likely to be
encountered beyond the neonatal age and mainly
include neuroblastomas, Wilms’ tumors, and
lymphomas.
 Abdominal masses are often treatable. However,
health complications may arise depending on the
cause of the mass.
 Masses in the abdomen are often described
by their location. The abdomen is divided
into four sections called quadrants. An
abdominal mass may occur in the RUQ,
LUQ, RLQ, or LLQ.
 Other terms used to find the location of
abdominal pain or masses include:
1. Epigastric -- located above the umbilicus
and below the ribs.
2. Periumbilical -- located below and around
the umbilicus.
Organ Malignant Diseases Nonmalignant Diseases

Adrenal Adrenal carcinoma Adrenal Adenoma


Neuroblastoma Adrenal Hemorrhage
Pheochromocytoma
Gall bladder Leiomyosarcoma Choledochal cyst
Gall Bladder obstruction
Hydrops (eg, leptospirosis)
Gastrointestinal tract Leiomyosarcoma Appendiceal abscess
Non-Hodgkin lymphoma Intestinal duplication
Fecal Impaction
Meckel's Diverticmulum
Kidney Lymphomatous nephromegaly Hydronephrosis
Renal cell carcinoma Multicystic kidney
Renal Neuroblastoma Polycystic kidney
Wilms tumor Mesoblastic nephroma
Renal Vein thrombosis
Hamartoma
genitourinary tract Ovarian germ cell tumor Bladder obstruction
Rhabdomyosarcoma of bladder Ovarian cyst
Rhabdomysarcoma of prostate Hydrocolpos
Organ Malignant Diseases Nonmalignant Diseases

Liver Hepatoblastoma Focal nodular hyperplasia


Hepatocellular carcinoma Hepatitis
Embryonal sarcoma Liver abscess
Liver metastases Storage disease
Mesenchymoma
Spleen Acute or chronic leukemia Congestive Splenomegaly
Histiocytosis Histiocytosis
Hodgkin lymphoma Mononucleosis
Non-Hodgkin lymphoma Portal hypertension
Storage disease
Miscellaneous Hodgkin lymphoma Teratoma
Non-Hodgkin lymphoma Abdominal hernia
Pelvic neuroblastoma Pyloric stenosis
Retroperitoneal neuroblastoma Omental or Mesenteric cyst
Retroperitoneal
rhabdomyosarcoma
Retroperitoneal germ cell
tumor
 Abdominal masses in neonates may originate
from the gastrointestinal tract. Duplications
are cystic congenital abnormalities of the
gastrointestinal tract that can occur at any level
from mouth to anus but most commonly involve
the ileum, followed by the esophagus and
duodenum. Duplications vary in size, have
spherical or tubular shapes, and may or may
not communicate with the enteric lumen. They
can present as asymptomatic masses or with
signs of obstruction, bleeding, and perforation.
Occasionally, duplications are only recognized at
the time of surgery. Surgical resection is usually
curative.
 is a narrowing of the pylorus, the opening from
the stomach into the small intestine, often in boys
than in girls, and is rare in children older than 6
months. The condition is usually diagnosed by the
time a child is 6 months old ,is felt classically as an
olive-shaped mass in the middle upper part or
RUQ of the infant's abdomen.
 projectile vomiting, belching, constant hunger
dehydration, Failure to gain weight or weight loss.
 The patient will be given IV fluids, usually before
surgery “Pyloroplasty “.
 Hydronephrosis is distention of the calyces and
pelvis of the kidney caused by obstruction at the
ureteropelvic junction, ureterovesicular
junction, or the bladder outlet and can be
unilateral or bilateral.
 Is often asymptomatic, unless damage of both
kidneys so severly that renal failure and uremia
result.
 The management of children with hydronephrosis
may be :
1. Supportive as many cases resolve spontaneously.
2. Decompression may be required when there is risk of
significant renal compromise or ongoing infection.
3. Resection of nonfunctioning kidneys is indicated for
complications such as infections and severe
hypertension.
 is a congenital maldevelopment in which the
renal cortex is replaced by numerous cysts of
multiple sizes.
 A dysplastic parenchyma anchors the cysts, the
arrangement of which resembles a bunch of
grapes. The calyceal drainage system is
absent, can result in reflux or blockage of
urine.
 Typically, is a unilateral disorder; the bilateral
condition is incompatible with life.
 no specific treatment. Over time, the
abnormal kidney regresses and just goes
away.
 Mesoblastic nephroma is the most common solid
renal tumor in neonates; it results from
proliferation of early nephrogenic mesenchyma.
 Hypertension has been reported with many renal
tumors, with or without hyper-reninemia. Most
cases present as masses or, less commonly, with
hematuria and may be detected prenatally.
Associated paraneoplastic syndromes have been
described, mainly hypercalcemia and
hypertension.
 Mesoblastic nephroma most often is a benign
lesion that is successfully treated by surgical
resection.
 Is fluid-filled sac , commonly occur in neonates and may also
be diagnosed prenatally. They are mostly functional cysts
stimulated by fetal, placental, and maternal hormones, the
incidence of malignancy in these cysts is extremely low.
 An ovarian cyst will usually only cause symptoms if it ruptures
(splits), is very large, or if it blocks the blood supply to the
ovaries, symptoms:
1. difficulty emptying bowels
2. a frequent need to urinate
3. indigestion or a feeling of fullness and bloating
 A significant proportion of cysts undergo spontaneous
regression within the first few months of life.
 Large-sized cysts, measuring more than 5 cm, may be
percutaneously aspirated to minimize the risk of torsion.
 Surgical intervention in neonates is generally discouraged
as a primary therapy and is reserved for persistent or
recurrent cases.
 Malignant lesions are more commonly
encountered as the cause of abdominal
masses in infants and children than in
neonates. The most common tumors are
neuroblastomas, Wilms’ tumors, and
lymphomas.
 Neuroblastoma is the most common malignancy in
infants and the most common extracranial solid tumor
in childhood. Neuroblastomas arise from neural crest
cells within the sympathetic chain or adrenal
medulla, with 60% to 70% of cases originating within
the abdomen.
 Presenting symptoms include a palpable mass, pain,
weakness, and failure to thrive. Other associated
signs include periorbital ecchymoses,
exophthalmos, and Horner’s syndrome (miosis,
ptosis and anhidrosis).
 Urinary catecholamines are elevated in 90% to 95%
of cases.
 Chemotherapy and surgical resection followed by
radiation therapy may be employed.
 Wilms’ tumor is the second most common abdominal tumor
in childhood and the most common primary pediatric renal
malignancy.
 It is an embryonal renal neoplasm, Presentations include a
flank or abdominal mass, hematuria, and hypertension. Such
masses can be quite large at diagnosis because they can go
unnoticed due to their retroperitoneal location and are
usually painless unless hemorrhage or rupture occurs. Wilms’
tumor may occur in association with other congenital anomalies
or syndromes.
 Wilms’ tumor is more likely to be bilateral and may present at a
younger age. Approximately 15% of patients will have
metastatic disease at diagnosis, most commonly affecting the
lungs followed by the liver and regional lymph nodes.
 Treatment includes surgery, if possible, radiation, and
chemotherapy.
 Lymphomas are the third most common
malignancies in childhood. 60% are non- Hodgkin
lymphomas and one third of these have abdominal
disease.
 Signs and symptoms include abdominal pain,
gastrointestinal obstruction, or a palpable mass.
Intussusception, secondary to a lymphomatous lead
point, can occasionally be the presenting picture.
 lesions tend to grow rapidly but are usually
responsive to chemotherapy.
 Surgical excision and occasionally radiation may
also be employed. Overall survival rates range
between 75% - 95%.
 Peripheral blood stem transplantation may be an
option for patients with advanced or recurrent
disease.
 Masses of ovarian origin, mostly ovarian cysts, are also
encountered in childhood. Such cysts are occasionally
associated with sexual precocity.
 Ovarian malignancies may be present in approximately 30% of
cases, especially when solid or complex structures are noted
within the mass. The most common of these malignant tumors
are Teratomas.
 teratoma is a type of cancer made of cysts that contain one or
more of the three layers of cells found in a developing baby
(embryo). These layers are called ectoderms, mesoderms, and
endoderms, symptoms:
1. Chest pain or pressure
2. Cough
3. Fatigue
4. Limited ability to tolerate exercise
5. Shortness of breath
 Ovarian malignancies in children are frequently found at an
early stage and tend to respond favorably to chemotherapy.
 Abdominal masses arising from the liver are often malignant and
include hepatoblastomas, embryonal sarcoma, HCC, or metastatic
disease. Less frequently occurring benign masses of hepatic
vascular origin include hemangioendotheliomas and hamartomas.

1. Hepatoblastomas are the most common liver malignancies in this


age group, accounting for at least 75% of cases.
 They may be congenital or familial and usually present with a rapidly
enlarging abdomen in an otherwise asymptomatic child. They are
derived from undifferentiated embryonal tissue.
 Treatment consists of surgical resection and chemotherapy , Liver
transplantation.

2. Embryonal sarcoma is a mesenchymal malignancy that accounts


for approximately 10% of all hepatic tumors in children.
 Presentations include an abdominal mass, swelling, or pain. Serum
alpha-fetoprotein levels are usually normal.
 Treatment with multiple modalities including adjunct chemotherapy,
radiation, and surgical resection .
1. Duplications.
2. Meckel’s diverticulum: pouch on the wall of the
lower part of the intestine that is present at birth
(congenital). The rule of 2s: 2% (of the population).
2 feet (proximal to the ileocecal valve). 2 inches (in
length). 2 types of common ectopic tissue (gastric
and pancreatic). 2 years is the most common age at
clinical presentation. 2:1 Male:Female ratio.
3. fecal masses : caused by severe constipation.
4. Omental or mesenteric cysts : is one of the rarest
abdominal tumors, The incidence is between 1 per
100,000 to 1 per 250,000 hospital admissions.
Now we will discuss them according to the abdominal regions :
RIGHT UPPER QUADRANT MASS
Common causes :
1-single liver mass :
• Riedel’s lobe : is an extension of the right lobe of the liver below the costal
margin in the anterior axillary line .
• a single palpable metastatic nodule :The colorectum, breast and lung are
the most common primary tumours to present with this condition
• Hydatid disease: is an important cause of an asymptomatic solitary liver
mass which is caused by echinococcus granulosus

• Other causes include simple cyst, polycystic disease, cystadenoma, liver


abscess and primary
hepatic carcinoma.
About half the patients with liver abscess have a previous history of liver
trauma.
2. Mucocele of the gall bladder
This can present as an asymptomatic mass beneath the tip of the right ninth
costal cartilage. The mass is smooth and rounded, moves on respiration,
cannot be separated by palpation from the liver and is dull to percussion.

3. Right renal swelling


This lies more laterally in the flank and extends posteriorly in the paracolic
gutter, moderate movement on respiration and resonance to percussion due to
overlying (right) colon. A renal mass is bimanually palpable and ballotable.

4. Carcinoma of the right colon


A hepatic flexure mass may be difficult to distinguish on physical examination
from a mass in the gall bladder or liver. A colonic mass tends to be hard and
irregular, with less movement on respiration. .
Less common causes of a right hypochondrial mass include high retrocaecal
appendiceal abscess, ileocaecal Crohn’s disease and pyloric masses. Gall
bladder carcinoma rarely presents as a palpable mass
LEFT UPPER QUADRANT MASS :
1- splenomaglay : its enlargment of the spleen , its usually associate with
increased workload such as hemolytic anemia .

2- enlarged left lobe of the liver

3- carcinoma of stomach or left colon : stomach ca is poor prognosis , it


could be asymptomatic or assosciates with non-spesific GI symptomes .

4- left renal tumor : Could be renal cell carcinoma (most common) or urothelial
cell carcinoma

5- retroperitoneal masses : When a tumor or cyst grows behind the visceral


peritoneum, but within the parietal peritoneum, it is called a retroperitoneal
mass.
EPIGASTRIC MASS :
Common causes:-
1. Gastric outlet obstruction with gastric dilatation

2. carcinoma of stomach or colon


Gastric carcinomas are often difficult to palpate because most tumours are
concealed by the rib cage within the upper abdomen. The dilated thick
walled stomach of gastric outlet
obstruction may be apparent as a soft resonant epigastric fullness.

3. abdominal aortic aneurysm(AAA) : localized dilatation (ballooning) of


the abdominal aorta exceeding the normal diameter by more than 50
percent, and is the most common form of aortic aneurysm.

4. retroperitoneal swelling ( pancreas or lymphoma )


immobile, indistinct on examination and often not felt.
5. small bowel crohns disease

6. mesenteric cyst : its very rare abdominal tumor


RHIGHT AND LEFT FLANK MASS :
Renal malignancy
:hydronephrosis
refers to distension and dilation of the renal pelvis and calyces, usually caused
byobstruction of the free flow of urine from the kidney.
Renal abscess
renal abscess is a very unusual disease, but generally occurs as a result of common
problems such as kidney inflammation, stone disease and vesicoureteral reflux
Renal tuberculosis
Polycystic kidney disease
Wilms tumour
nephroblastoma is cancer of the kidneys that typically occurs in children, rarely
in adults
Intestinal lymphoma
Lipoma
Adrenal tumour
Renal vein thrombosis
Hepatomegaly - massive
Splenomegaly - massive
Gastrointestinal malignancy
PERIUMBILICAL MASS :

Abdominal aortic aneurysm (AAA) : pulsatile mass

umbilical and peri umbilical hernia

# mesentric cyst : Rare intra abdominal tumer in the mesentry its usually
benign and can be vary larg fluid filled cyst

Vulvulus : bowel obstruction of loop of bowel which is completely twisted


around the site of mesentric attachment

Duplication of small intestine :


un common conginital ubnormality it can occure any where through the
alimentary tract

Intestinal neoplasm : very rare in relation to other gastrointestinal tumres


RIGHT ILIAC FOSSA
Carcinoma of the caecum : it’s the least common site for colon
ca

Chronic appendiceal abscess

Ileocaecal Crohn’s disease

LESS COMMON causes :


These include chronic inflammatory disorders of the caecum
(yersinia, tuberculosis, actinomycosis and right colonic
diverticulitis). Iliac artery aneurysm, iliac lymph
nodes,chondrosarcoma of the ilium, kidney abnormality,
intussuseption , ovarian tumer , tumer in intra abdominal testis
LEFT ILIAC FOSSA
Diverticulitis : sigmoid colon is the most common site

:Carcinoma of the sigmoid colon the most common site of


colon ca

Faecal masses in the sigmoid colon

Less common causes


These include iliac artery aneurysm, psoas abscess, iliac
lymphadenopathy and tumours of the kidney abnormality,
intussuseption , ovarian tumer , tumer in intra abdominal testis
.
SUPRAPUPIC REGION :

Distended bladder :May extend up to the umbilicus at extreme


cases

The pregnant uterus

Uterine fibromyomas

Ovarian tumours and cysts, tubo-ovarian masses

Neurobalstoma ( in children and infant ) : its neuroendocrine


tumer

Uteropelvic junction obtruction


I. Careful and detailed history
II. Physical examination
III. Investigations (laboratory studies and
imaging techniques)
 Questions to ask
› Patient’s data (age, gender, occupation)
› Where was the mass observed?
› When was it first noticed?
› How was it noticed?
─ What symptoms does it cause?
─ How has it changed since it was first noticed?
─ Has it ever disappeared or healed?
─ Has the patient ever had any other masses?
─ What does the patient think caused it?
 It has three main objectives
› Evaluate the patient's condition as it directly or
indirectly relates to the mass.
› Help assess the acuteness of the patient's
condition.
› Examine each abdominal quadrant, assessing
both normal and abnormal anatomic relations as
possible sources of the presumed mass.
 Look at the whole patient. Look for any general
abnormality indicative of intra-abdominal pathology
such as cachexia, pallor or jaundice
 Inspection of the abdomen from the end of the bed will
reveal if there is any asymmetry or distension
 Note the position, shape and size of any bulge, any
changes in its shape and whether it moves with
respiration or increases with coughing
 Observe the reaction of the patient to coughing or
moving
 Record the presence of any scars, sinuses or fistulae
 Dilated veins may indicate the possibility of portal
hypertension or inferior vena caval occlusion
 Umbilicus
 Hair distribution
 Discoloration
 Superficial, deep and organ-specific
 Check for guarding, rigidity and tenderness
 Palpation for masses
› Is it within anterior abdominal wall or within
abdominal cavity?
› Is it an enlarged abdominal organ or separate
from the solid organs?
› If separate, is it a tumor, abscess or palpable
feces within the colon?
 Describe the mass (SPACESPIT)
› Size
› Position
› Attachments
› Consistency
› Edge
› Surface and shape
› Pulsation, thrills and bruits
› Inflammation
› Transillumination
 Helps detect organ or mass size.
 Assists in differentiating the underlying
components
› Solid masses and fluid-filled cysts are typically dull
to percussion
› air-filled structures are tympanic
 Test for ascites (shifting dullness, fluid thrill).
 Succussion splash indicate that there is an
intra-abdominal viscus, usually the stomach,
distended with a mixture of fluid and gas.
 Listen to the bowel sounds
› Normal bowel sounds are low-pitched gurgles
› Absent/diminished bowel sounds indicate an ileus
› High pitched and "tinkling" sounds indicate bowel
obstruction
 Bruits are "swishing" sounds heard over major
arteries. The area over the aorta, both renal arteries
and the iliac arteries.
 Rubs are infrequently found on abdominal
examination but can occur over the liver, spleen, or
an abdominal mass.
 The choice of laboratory studies is guided by
the type of symptoms and signs that are
involved.
 Studies to be considered include:
 Urinalysis
 Complete blood cell count
 Blood urea nitrogen and creatinine
 Electrolytes
 Hepatic transaminases and bilirubin
 Abdominal CT scan
 Abdominal ultrasound
 Abdominal x-ray
 Barium enema
 Colonoscopy
 EGD
 Isotope study
 Sigmoidoscopy
 It makes a detailed picture of the structures
inside the abdomen.
 This test may be used to look for:
› Masses and tumors, including cancer
› Cause of abdominal pain or swelling
› Hernia
› Cause of a fever
› Infections or injury
› Kidney stones
› Appendicitis
 It uses high frequency sound waves to produce
two-dimensional images of the body's soft
tissues.
 Many possible conditions can be revealed by an
abdominal ultrasound, some of these include:
› Abdominal aortic aneurysm
› Hydronephrosis
› Splenomegaly
› Abnormal growths - tumors, cysts, abscesses, scar
tissue and accessory organs. In particular, potentially
malignant solid tumors can be distinguished from
benign fluid-filled cysts.
 Abnormal findings include:
› Abdominal masses
› Buildup of fluid in the abdomen
› Certain types of gallstones
› Foreign object in the intestines
› Hole in the stomach or intestines
› Injury to the abdominal tissue
› Intestinal blockage
› Kidney stones
 Barium enema is a special x-ray of the large
intestine, which includes the colon and rectum.
 It is used to detect colon cancer, although it is
used much less often than in the past.
 It may also be used to diagnose and evaluate
the extent of inflammatory bowel disease (IBD)
or other bowel disease.
 This test can help diagnose the cause of:
› Abdominal pain
› Diarrhea, constipation or other changes in bowel
habits
› Blood, mucus or pus in the stool
› Weight loss
 It can also be used to:
› Confirm findings of another test or x-rays
› Screen for colorectal cancer or polyps
› Take a biopsy of a growth
 Bailey & Love’s – short practice of surgery
26th edition.
 http://emedicine.medscape.com/