Approach to a patient with abdominal lump

Epigastric region

  • Structures-liver and subphrenic abscess, stomach, duodenum, transverse colon, omentum, pancreas, abdominal aorta, LN.
    • Congenital Hypertrophic pyloric stenosis
    • Gastric torsion
    • Pseudo pancreatic cyst, pancreatic abscess
    • Hepatomegaly
    • Gastroparesis
    • Intussusception
    • Duplication of stomach/duodenum

Right Hypochondrium

  • Structures- liver, gallbladder, subphrenic space, hepatic flexure of the colon, rt. Kidney and suprarenal glands.
    • Hepatomegaly
    • Choledochal cyst
    • Subphrenic abscesses
    • Kidney swelling

Causes of Hepatomegaly

Infections
  • Viral- congenital rubella, CMV, hepatitis infection, infectious mononucleosis, viral infection, HIV
  • Bacterial- septicaemia, tuberculosis, congenital syphilis, pyogenic liver abscess.
  • Parasitic infections- hydatid cyst, toxoplasmosis, amoebic liver abscess, malaria & kala-azar.
Hematological/ Reticuloendothelial
  • Thalassemia, sickle cell disease, ALL, AML, CML.
  • Non- Hodgkin lymphoma, Hodgkin disease.
Congestive
  • CCF, constrictive pericarditis, Pericardial effusion, Budd Chiari syndrome, the venous-occlusive disease of the liver.
Infiltrative
  • Histiocytosis
  • sarcoidosis
Structural/Metabolic
  • Sphingolipidoses - Gaucher disease, Niemann-Pick disease
  • Mucolipidoses, Mucopolysaccharidosis
  • GSD (type 1,3,4,6), Galactosemia
  • Tyrosinaemia type I, UreaCycle enzyme disorders.
  • Wilson disease
  • Cystic fibrosis
  • Alpha- 1- antitrypsin deficiency
  • Hyperlipoproteinemias
  • PEM
Connective tissue disorder
  • Systemic JRA, SLE
Tumor/hamartoma
  • Primary hepatic neoplasms: hepatoblastoma, hepatocellular carcinoma
  • Vascular tumors in the liver
  • Secondary deposits: neuroblastoma, Wilm’s tumor, gonadal tumors.
Trauma
Hepatic hematoma
Drugs
Tetracycline toxicity

Left Hypochondrium

  • Structures- spleen, stomach, left lobe of the liver, splenic flexure of the colon, the tail of the pancreas, lt kidney and suprarenal gland.
    • Splenomegaly
    • Enlarged Kidney

Cause of splenomegaly

  • Infection
    • Viral – infectious mononucleosis, CMV, HIV
    • Bacterial – Subacute bacterial endocarditis, typhoid, septicemia, tuberculosis, brucellosis
    • Protozoal infection – malaria, kala-azar, toxoplasmosis.
  • Hematological
    • Chronic hemolytic anemias
  • Connective tissue disease
    • Systemic JRA, SLE, Felty’s synd, Behcet’s disease, Sjogren's syndrome
  • Portal hypertension
    • Extrahepatic- postneonatal umbilical vessel catheterization or sepsis, Budd- Chiari syndrome
    • Hepatic- cirrhosis (post viral, autoimmune hepatitis, Wilson's disease, other metabolic causes)
  • Sarcoidosis
  • Hypereosinophilic syndrome
  • Malignancy
    • Leukaemia, Lymphoma
  • Storage diseases
    • Gaucher’s, Niemann- Pick disease
  • Splenic cyst, tumor, abscess or hamartoma
  • Injury - Splenic Hematoma

Right/Left Lumbar region

  • Structures- kidney, ascending & descending colon.
Unilateral flank mass
  • Tumor
Renal- Wilms tumor, renal cell carcinoma, Congenital mesoblastic nephroma.
Non renal- Neuroblastoma, Adrenal cell carcinoma, Pheochromocytoma
  • Hydronephrosis
  • Hypertrophied solitary kidney.
  • Renal cyst.
  • Renal vein thrombosis.
  • Perinephric abscess
Bilateral flank mass
  • Polycystic kidney disease
  • Hydronephrosis- PUV, VUR, neurogenic bladder, phimosis, meatal stenosis, urethral stone.
  • Tumor- Wilms, leukemia, lymphoma, tuberous sclerosis.
  • Metabolic – GSD type 1, Tyrosinemia type 1

Umbilical region

  • Intussusception
  • Volvulus
  • Duplication of the small intestine
  • Mesenteric/Omental cyst
  • Matted coils of intestines with tuberculous mesenteric lymphadenitis
  • Lymphoma, Teratoma
  • Toxic megacolon

Right iliac fossa

  • Structures- appendix, caecum, terminal ileum, LN, tubes & ovary.
  • Appendicular mass, abscess, tumor
  • Hyperplastic ileocaecal TB
  • Impaction of roundworms in the ileum, rarely trichobezoar.
  • Iliac abscess, iliopsoas abscess
  • Tubo-ovarian mass, Dermoid, Torsion of the ovary, Follicular cyst.
  • Unascended kidney
  • Undescended testis

Left iliac fossa

  • Structures – sigmoid colon, tubes & Ovary
  • Feces – constipation

Hypogastrium

  • Structures- urinary bladder, sigmoid colon, uterus, and its appendages.
    • Distended urinary bladder
    • Gravid uterus
    • Pelvic abscess
  • lumps in parietal wall
    • Umbilical, epigastric, inguinal, femoral hernia
    • Umbilical granuloma
    • Congenital polyp or adenoma arising from patent vitelline duct.
    • Omphalocele/,Gastroschisis
    • Trauma (rectus hematoma)
    • Cysts (sebaceous cyst)
    • Tumor (fibroma, lipoma, rhabdomyosarcoma)
    • Urachal cyst in hypogastrium
    • Parietal wall abscess

APPROACH

  • With all abdominal masses, an assessment of the child's age and clinical state is important in determining the diagnosis.

Abdominal masses in the newborn:

  1. Renal masses (55%): hydronephrosis, multicystic dysplastic kidney, polycystic kidney, Mesoblastic nephroma/Wilm's tumor, renal vein thrombosis, renal ectopia
  2. Genital masses (15%): hydrometrocolpos, ovarian cyst
  3. GI masses (15%): duplications, obstruction, mesenteric/omental cyst, splenic hematoma/cyst, meconium peritonitis
  4. Hepatobiliary (5%): liver cyst, liver tumor, choledochal cyst, hydrops of gall bladder, neuroblastoma (metastasis)
  5. Retroperitoneal masses (5%): lymphangioma, extra-adrenal neuroblastoma, anterior meningocele, teratoma, rhabdomyosarcoma
  6. Adrenal masses (5%): neuroblastoma, adrenal hemorrhage

History

  • Age – intussusception
  • Sex – for X- linked diseases
  • Residence – Malaria, Kala-azar
  • Duration – recent or chronic
  • Fever – hepatitis, infectious mononucleosis, TB, malaria, kala-azar
  • Vomiting – hepatitis, Hypertrophic pyloric stenosis, meconium peritonitis
  • Jaundice – EHBA, hepatitis
  • Increasing pallor – chronic hemolytic anemia, malignancy
  • Abdominal pain - sickle cell anemia
  • Rashes – SLE, systemic onset JRA
  • Seizure – Inborn error of metabolism
  • Shortness of breath - CCF
  • H/o recent weight loss - Malignancy
  • H/o failure to thrive – Chronic liver/kidney disease
  • Swelling of abdomen/body – cirrhosis, CCF
  • Bony tenderness- leukemia
  • Frequency and quality of bowel habit: red currant jelly-intussusception, whitish stool - EHBA
  • Hematuria or dysuria – renal disease
  • Retention of urine with H/O straining - PUV
  • H/O abdominal trauma – hematoma, pseudopancreatic cyst
  • H/O mental retardation – galactosemia
  • Past history - jaundice
  • H/O frequent chest infection - Cystic fibrosis, Alpha-1 antitrypsin deficiency, GSD 2.
  • H/o blood transfusion in past – hemolytic disease, hepatitis B, C
  • Contact history – Tuberculosis
  • H/O similar problem in siblings – storage diseases
  • H/o consanguinity – Thalassemia
  • Drug history – drug-induced hepatitis

Physical Examination

  • Vitals – temp, blood pressure
  • Anthropometry
  • Microcephaly- rubella
  • Macrocephaly with hydrocephalus – toxoplasmosis
  • Icterus- liver diseases, hemolytic anemia
  • Pallor – Hemolytic anemia, leukemia
  • Clubbing- Crohn’s disease, SBE
  • Lymphadenopathy- TB, HIV, CMV infection Infectious mononucleosis, Leukemias, lymphomas
  • Pedal edema- CCF, Chronic liver diseases, liver failure.
  • JVP – raised in CCF, pericardial effusion, constrictive pericarditis.
  • Peripheral stigmata of CLD – bruising, spider naevi
  • Facial characteristic
  • Thalassemic face
  • Cushingoid face (adrenal tumor, during Rx of nephrotic),
  • Coarse face ( Mucopolysaccharidosis, Hypothyroidism)
  • Mouth
  • Palatal petechiae, Gum bleeding
  • Oral ulcers
  • Eye
  • Xanthelasma - hyperlipoproteinemias
  • Aniridia- Wilm's tumor
  • proptosis –neuroblastoma
  • Kayser- Fleischer ring in cornea- Wilson's disease
  • Xerosis - Sjogren’s syndrome
  • Corneal clouding- MPS IH & IS
  • Cataract –Galactosaemia, toxoplasmosis, CMV, Rubella infections
  • Uveitis- Pauciarticular JRA, TB, Sarcoidosis, Behcet’s disease
  • Chorioretinitis – CMV, Toxoplasmosis
  • Cherry red spot- Niemann-pick disease
  • Macroglossia – Mucopolysaccharidoses, Hypothyroidism
  • Deafness- TORCH
  • Skin rashes, petechiae - leukemias
  • Joint swelling/ arthritis – SLE, JRA, Behcet’s disease, Sjogren’s syndrome
  • Skeletal changes of rickets- tyrosinosis, cystinosis
  • Bony tenderness in leukemias
  • CVS
  • Evidence of congenital heart disease - TORCH infection
  • Hepatomegaly, tachypnoea, tachycardia, raised JVP, mild icterus in CCF, Pericardial diseases.
  • CHEST
  • For signs of infection- Cystic fibrosis, alpha1 antitrypsin deficiency presents with frequent infections.
  • Pigeon chest- tyrosinosis
  • CNS
  • Alertness – TORCH, Hypothyroidism
  • Choreoathetosis movements- Wilson
  • Pathological persistence of primitive reflexes- TORCH
  • Hemihypertrophy
  • Wilm’s tumor, hepatoblastoma

Abdominal Examination

Inspection

  • Position, Size & Shape
  • The condition of skin over the swelling
  • Movement with respiration/ other direction
  • Visible peristalsis
  • Hernial sites
  • Scrotum

Palpation

  • Local Temperature
  • Tenderness
  • Position, size, shape, and surface
  • Margin
  • Consistency
  • Movement
  • Parietal or intraabdominal
  • Is the swelling pulsatile or not
  • Hernial site and per rectal examination

Percussion

  • Solid organ – dull ( liver, spleen, solid tumor)
  • Coils of the intestine- resonant
  • Kidney swelling will have a band of resonance unless kidney is very much enlarged.
  • Loin percussion just lateral to the lateral border of erector spinae- dull in kidney swellings.
  • Shifting dullness

Auscultation

Investigation

  • USG abdomen/ doppler – most useful, the primary imaging modality in the abdominal lump. -Neuroblastoma often contains calcium and encases the major abdominal vessels.
    -Wilm's tumor displaces the central vessels and rarely calcifies.
  • Abdominal Xray – obstruction, perforation.
  • Barium swallow/ enema/ follow through
  • Nuclear scintigraphy, CT and MRI are used for malignant or complicated cases
  • HIDA scan
  • Intravenous urography
  • ECHO
  • CBC, Peripheral smear, ESR - Infections
  • Reticulocyte count, RBC indices G6PD, Sickling, Osmotic fragility test - in susp[icion of hemolytic anemia
  • Mantoux test
  • Biochemistry – depending on clinical suspicion. RBS, electrolytes, LFT, RFT.
  • Serology: Viral markers, HBsAg test, HIV test, TORCH titer.
  • Microscopy, culture/sensitivity
  • Urinary copper excretion.
  • Metabolic screening
  • Stool examination: for ova, parasites, occult blood.
  • Esophagogastroduodenoscopy, colonoscopy, sigmoidoscopy.
  • Tissue biopsy – LN, mass
  • Bone marrow biopsy- leukemia, Kala-azar.
  • Laparoscopy – direct intraperitoneal visualization and biopsy of tissue, also helpful in the staging of the tumor.

Management

  • First, we have to evaluate the clinical state of the patient for management
  • Managed according to the cause.

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