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| Shown below is an algorithm summarizing the diagnosis of <nowiki>abdominal mass</nowiki> according the the [...] guidelines.
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| {{familytree/start |summary=PE diagnosis Algorithm.}}
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| {{familytree | | | | A01 | | | A01=Abdominal mass}}
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| {{familytree | | | | |!| | | | }}
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| {{familytree | | | | B01 | | | B01=History and brief physical exam<br> Past medical history}}
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| {{familytree | | |,|-|^|-|.| | }}
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| {{familytree | | C01 | | C02 | C01=Hemodynamic instability | C02= Stable}}
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| {{familytree | | ! | | | ! | | | }}
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| {{familytree | | | | | | | | | }}
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| <span style="font-size:85%"> '''Abbreviations:''' '''ACS:''' Acute coronary syndrome; '''AAA:''' Abdominal aortic aneurysm; '''RUQ:''' Right upper quadrant; '''RLQ:''' Right lower quadrant; '''LUQ:''' Left upper quadrant; '''LLQ:''' Left lower quadrant</span>
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| {{familytree/start |summary=Acute abdominal pain}}
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| {{familytree | | | | | | | | | | | | | | A01 | | | | | | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Characterize the mass''':<br>
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| :❑Pulsatile mass
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| :❑Constant mass
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| <br>
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| '''Associated [[pain]]:'''<br>
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| :❑ Site (eg, a particular quadrant or diffuse, a change in location may reflect progression of the [[disease]]
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| :❑ Onset (eg, sudden, gradual)
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| :❑ Quality (eg, dull, sharp, colicky, waxing and waning)
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| :❑ Aggravating and relieving factors (e.g, Is the pain related to your meals?)
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| :❑ Intensity (scale of 0-10/ 0-5 with the maximum number; 10/5 being the worst pain of life)
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| :❑ Time course (eg, hours versus weeks, constant or intermittent)
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| :❑ Radiation (eg, to the shoulder, back, flank, groin, or chest)<br>
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| '''Associated [[symptoms]]'''<br>
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| :❑ [[Shortness of breath]]
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| :❑ [[Altered mental status]]
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| :❑ [[Nausea]] & [[vomiting]]
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| :❑ [[Diaphoresis]]
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| :❑ [[Fever]]
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| :❑ [[Hematuria]]
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| :❑ [[Anorexia]]
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| :❑ [[Bloody stool]]
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| :❑ [[Weight loss]]
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| :❑ [[Vaginal discharge]]
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| :❑ [[Penile discharge]]
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| :❑ [[Jaundice]]
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| :❑ [[Mal-digestion]]
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| :❑ [[Flatulence]]
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| :❑ [[Fatigue]]
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| :❑ [[Scrotal pain/swelling]]
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| :❑ Recent trauma
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| :❑ Symptoms suggestive of [[Sepsis history and symptoms|sepsis]]
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| '''Detailed history:'''<br>
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| :❑ Age (Patients above 50 years old are more likely to have severe diseases or cancers, such as ruptured [[abdominal aortic aneurysm]] or [[colon cancer]])
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| :❑ Past medical history (to exclude risk factors for cardiovascular diseases or peripheral vascular disease)
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| :❑ Past surgical history (for previous abdominal surgeries)
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| :❑ Menstrual and contraceptive history (pregnancy should be excluded in all women of childbearing age with abdominal mass)
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| :❑ Social history (alcohol abuse predispose to pancreatitis and hepatitis, smoking also predisposes to different types of cancers, eg. cancer bladder, which may cause abdominal pain)
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| :❑ Occupational history (exposure to chemicals or toxins)
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| :❑ Travel history
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| :❑ Medications (for over the counter drugs as</div>}}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | A02 | | | | | | A02= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Examine the patient:''' <br>
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| ❑ Vital signs<br>
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| :❑ [[Temperature]]<br>
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| :❑ [[Heart rate]] ([[tachycardia]]) <br>
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| :❑ [[Blood pressure]] ([[hypotension]])<br>
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| :❑ [[Respiratory rate]] ([[tachypnea]])<br>
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| ❑ Skin <br>
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| :❑ [[Diaphoresis]]
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| :❑ [[Pallor]]
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| :❑ [[Jaundice]]
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| :❑ [[Dehydration]]
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| ❑ Inspection <br>
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| :❑ If the patient is lying still in bed with knees bent, this is suggestive of organ rupture and resulting [[peritonitis]]<br>
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| :❑ Signs of previous surgery<br>
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| :❑ Abdominal pulsations<br>
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| :❑ Signs of systemic disease eg,<br>
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| ::❑ [[Pallor]], suggestive of bleeding<br>
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| ::❑ [[Spider angiomata]], suggestive of [[cirrhosis]]<br>
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| ❑ Auscultation <br>
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| :❑ Abdominal crepitations<br>
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| :❑ Reduced bowel sounds<br>
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| :❑ Increased bowel sounds<br>
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| :❑ Bruit, suggestive of [[abdominal aortic aneurysm]]<br>
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| ❑ Palpation<br>
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| :❑ Rigidity
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| :❑ [[Guarding]]
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| :❑ Abdominal tenderness
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| :❑ [[Distension]]
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| :❑ Detection of masses on palpating the abdomen
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| :❑ [[Carnett's sign]]
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| ❑ [[Psoas sign]] (suggestive of retrocecal appendix)<br>
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| ❑ [[Cullen's sign]]<br>
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| ❑ [[Grey-Turner's sign]]<br>
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| ❑ [[Digital rectal exam]] (tenderness may be present in retrocecal appendicitis)<br>
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| ❑ [[Pelvic exam]] in females<br>
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| ❑ [[Testicular examination]] in males<br>
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| ❑ Cardiovascular system<br>
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| ❑ Respiratory system<br>
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| ❑ Anorectal (bleeding)<br>
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| ❑ [[Signs of sepsis]]: [[tachycardia]], decreased urination, and [[hyperglycemia]], [[confusion]], [[metabolic acidosis]] with compensatory [[respiratory alkalosis]], [[low blood pressure]], decreased [[systemic vascular resistance]], higher [[cardiac output]], and [[coagulation]] dysfunctions<br>
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| </div>}}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | | | }}
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| {{familytree | | | | | | | | | | | | | | C01 | | | | | | | |C01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider extraabdominal differential diagnosis:'''<BR> ❑ aaaa</div>}}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | | | }}
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| {{familytree | | | | | | | | | | | | | | E01 | | | | | | | | | |E01=❑ Assess hemodynamic stability }}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | Z02 | | | | | | | | |Z02=<div style="float: left; text-align: left; line-height: 150% ">'''If the patient is unstable,''' <br> '''Stabilize the patient:'''<br> ❑ Establish two large-bore intravenous peripheral lines<br> ❑ [[NPO]] until the patient is stable<br> ❑ Supportive care (fluids and electrolyes as required)<br> ❑ Place nasogastric tube if there is bleeding, obstruction, significant [[nausea]] or [[vomiting]]<br> ❑ Place [[foley catheter]] to monitor volume status<br> ❑ Cardiac monitoring<br> ❑ Supplemental oxygen as needed<br> ❑ Administer early antibiotics if indicated </div>}}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | Z01 | | | | | | | | | | |Z01 =<div style="float: left; text-align: left; line-height: 150% ">'''If the patient is stable,'''<br> '''Order laboratory tests:'''<br> ❑ [[Pregnancy test]] (required in women of child-bearing age) <br>❑ [[CBC]]<br> ❑ [[Hematocrit]]<br> ❑ [[Urinalysis]]<br> ❑ [[Serum electrolytes]]<br>❑ [[ESR]]<br>❑ [[ABG]]<br> ❑ [[D dimer]]<br>❑ [[Serum lactate]]<br> ❑ [[BUN]] <br> ❑ [[Creatinine]] <br> ❑ [[Amylase]] <br> ❑ [[Lipase]] <br> ❑ [[Triglyceride]] <br>❑ Total [[bilirubin]]<br>❑ Direct [[bilirubin]]<br>❑ [[Albumin]]<br>❑ [[AST]]<br>❑ [[ALT]]<br>❑ [[Alkaline phosphatase]]<br>❑ [[GGT]]<br>❑ Stool for ova and parasites<br>❑ C. difficile culture and toxin assay
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| ----
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| '''Order imaging studies:''' <br> ❑ Order urgent trans abdominal [[ultrasound]] (TAUSG)<br> ❑ [[Abdominal CT]]<br> ❑ [[ECG]]<br> ❑ [[MRCP]] <br> ❑ [[Abdominal x-ray]] <br> ❑ [[Angiography]]<br> ❑ Diagnostic [[paracentesis]]<br>
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| ----
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| '''''*Order the tests to rule in a suspected diagnosis<br> or to assess a case of unclear etiology'''''<br> '''''*In case of elderly patients, immunocompromised<br> or those unable to provide a comprehensive<br> history, order broader range of tests''''' </div>}}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | A01 | | | | | |A01=<div style="float: left; text-align: left; line-height: 150% "> '''Signs of [[peritonitis]] or [[shock]]'''<br> ❑ [[Fever]]<br> ❑ Abdominal tenderness<br> ❑ Abdominal gaurding<br> ❑ Rebound tenderness ([[blumberg sign]])<br> ❑ Diffuse abdominal rigidity<br> ❑ [[Confusion]]<br> ❑ Weakness<br> ❑ Low blood pressure <br> ❑ Decreased urine output<br> ❑ Tachycardia<br> </div>}}
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| {{familytree | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
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| {{familytree | | | | | | | C01 |-|-|-|-|-|.| | | | | | C03 | | | | | | | |C01=No|C02=No|C03=Yes}}
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| {{familytree | | | | | | | |!| | | | | | |!| | | | | | |!| }}
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| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
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| {{familytree/end}}
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| {{familytree/start |summary=Pulsatile abdominal mass management Algorithm.}}
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| {{familytree | | | | | | | | A01 |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Pulsatile abdominal mass'''<ref name="pmid22470694">{{cite journal |vauthors=Moussa O, Al Samaraee A, Ray R, Nice C, Bhattacharya V |title=A Tender Pulsatile Epigastric Mass is NOT Always an Abdominal Aortic Aneurysm: A Case Report and Review of Literature |journal=J Radiol Case Rep |volume=4 |issue=10 |pages=26–31 |date=2010 |pmid=22470694 |pmc=3303349 |doi=10.3941/jrcr.v4i10.458 |url=}}</ref><ref name="urlAbdominal aortic aneurysm | Radiology Reference Article | Radiopaedia.org">{{cite web |url=https://radiopaedia.org/articles/abdominal-aortic-aneurysm#:~:text=CT%20angiography%20(CTA)%20is%20considered,arteries%20and%20the%20aortic%20bifurcation. |title=Abdominal aortic aneurysm | Radiology Reference Article | Radiopaedia.org |format= |work= |accessdate=}}</ref><ref name="urlwww.nice.org.uk">{{cite web |url=https://www.nice.org.uk/guidance/ng156/documents/short-version-of-draft-guideline |title=www.nice.org.uk |format= |work= |accessdate=}}</ref><ref>{{cite book | last = Starnes | first = Benjamin | title = Ruptured abdominal aortic aneurysm : the definitive manual | publisher = Springer | location = Cham | year = 2017 | isbn = 9783319238449 }}</ref><br>❑History (such as associated pain, past medical, surgical history)<br>❑Physical exam (such as location and extent of the mass, change in size) <br>❑Risk factors for the development of [[AAA|Abdominal AOrtic Aneurysm]] (AAA)}}
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| {{familytree | | | | | | | | |!| | | | | | }}
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| {{familytree | | | | | | | | D01| | | | | |D01=Assess hemodynamic stability }}
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| {{familytree | | | | |,|-|-|-|^|-|-|-|.| | | }}
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| {{familytree | | | B01 | | | | | | | B02 | | |B01= '''Unsable'''|B02= '''Stable'''}}
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| {{familytree | | | |!| | | | | | | | |!| }}
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| {{familytree | | | C01 | | | | | | | G01| |C01=<div style="float: left; text-align: left; line-height: 150% ">❑'''A'''irway, '''B'''reathing and '''C'''irculation (ABC)<br>❑Clinical diagnosis of ruptured [[AAA]] considered if patient is/was a smoker, >60 years old,<br> [[HTN]] history, an existing diagnosis of [[AAA]], and abdominal/back pain. <br>❑Immediate bedside aortic [[US]]<br>❑[[Systolic blood pressure|Systolic BP]] >70 acceptable (permissive hypotension)|G01=<div style="float: left; text-align: left; line-height: 150% ">❑Abdominal [[ultrasound]] scan (US)<br>
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| ❑Abdominal [[ultrasound|US]] (100% [[sensitivity|Sn]] and [[specificity|Sp]] but visualization among 1-3% [[patients]])<br>❑[[CT angiogram|CTA]] serves as first line modality to assess [[AAA]] in few cases}}
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| {{familytree | | | |!| | | | | | | | |!| }}
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| {{familytree | | | D01 |-| D03 | | | |!|D01=<div style="float: left; text-align: left; line-height: 150% ">Emergency repair (open or endovascular) if expertise are available|D03=<div style="float: left; text-align: left; line-height: 150% ">Transfer to a facility with vascular specialist expertise}}
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| {{familytree | | | | | | | | | | | | |!| }}
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| {{familytree | | | | | | | | | | | | |!| |}}
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| {{familytree | | | | | | | | | | | | |!| }}
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| {{familytree | | | | | | | | |,|-|-|-|^|.| }}
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| {{familytree | | | | | | | | E01 | | | E02 |E01='''[[AAA]] not demonstrated'''|E02='''[[AAA]] demonstrated'''}}
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| {{familytree | | | | | | | | |!| | | |!| }}
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| {{familytree | | | | | | | | F01 | | |!| F01=<div style="float: left; text-align: left; line-height: 150% ">Look for other possible causes on a [[CT]] scan<br>
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| ❑[[Heart failure]] ([[hepatomegaly]], [[portal hypertension]], [[pulmonary edema]], and contrast reflux into [[IVC]] and [[hepatic veins]])<br>
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| ❑Colonic diverticula with peri-colic inflammation and fluid collection<br>
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| ❑Dilatation of renal pelvicalyceal systems, [[splenomegaly]]<br>
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| ❑Tumors (distinct mass or diffuse organ infiltration, [[LAD]], metastasis to other organs)<br>
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| ❑[[Pancreatic pseudocyst]] (Large cyst/multiple cysts in and around the pancreas with [[calcifications]] maybe, [[splenic vein thrombosis]], and [[pseudoaneurysm]]s of [[splenic artery]], bleeding into a pseudocyst}}
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| {{familytree | | | | | | | | | | | | |!| }}
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| {{familytree | | | | | | |,|-|-|-|-|-|^|.|}}
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| {{familytree | | | | | | G01 | | | | | | G02 |G01='''<5.5cm'''|G02='''≥5.5cm'''}}
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| {{familytree | | | | | | |!| | | | | | | |!| | }}
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| {{familytree | | |,|-|-|-|^|-|.| | | | |,|^|-|-|-|.|}}
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| {{familytree | | E01 | | | | E02 | | | E03 | | | E04 | E01=<div style="float: left; text-align: left; line-height: 150% ">'''No pain demonstrated'''<br>Rupture risk<operative repair risk (1 year)|E02=<div style="float: left; text-align: left; line-height: 150% ">'''Pain is present'''<br> Search for risk factors: female, [[smoker]],<br> height, [[age]], [[HTN]] history or other causes|E03=<div style="float: left; text-align: left; line-height: 150% ">'''No Pain demonstrated'''<br>Rupture risk>operative repair risk (1 year)<br>Elective repair considered|E04=<div style="float: left; text-align: left; line-height: 150% ">'''Pain is present'''<br>High rupture risk}}
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| {{familytree | |!| | | |,|-|-|^|.| | | | | | | | |!| | }}
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| {{familytree | |!| | | H01 | | H02 | | | | | | | |!| | | H01=<div style="float: left; text-align: left; line-height: 150% ">Other causes<br>(low rupture risk)|H02=<div style="float: left; text-align: left; line-height: 150% ">No other causes <br>(moderate-high risk of rupture)}}
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| {{familytree | |!| | | |!| | | |`|-|-|-|-|-|-|-| F01| |F01=<div style="float: left; text-align: left; line-height: 150% ">❑[[RFTs]]<br>
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| :❑[[Creatinine|Crt]]<2mg/dl=[[CT angiography|CTA]]<br>
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| :❑[[Creatinine|Crt]]>2mg/dl or dye allergy=[[MR angiography|MRA]]}}
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| {{familytree | |`| K01 |'| | | | | | | | | | | | |!| | K01=<div style="float: left; text-align: left; line-height: 150% ">❑Follow-up in 6M<br>
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| ❑Repair of [[aneurysm]] if it grows >0.4cm/year or becomes symptomatic<br>
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| ❑Patient education}}
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| {{familytree | | | | | | | | | | | | | | | | |,|-|^|.|}}
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| {{familytree | | | | | | | | | | | | | | | | I01 | | I02 | |I01=<div style="float: left; text-align: left; line-height: 150% ">❑'''Unruptured [[AAA]]''' (moderate risk)<br>
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| :❑Hyperattenuating crescent sign, >150% normal diameter of [[aorta]], [[mural thrombus]] and [[calcification]]<br>
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| ❑Consider elective repair|I02=<div style="float: left; text-align: left; line-height: 150% ">❑'''Ruptured [[AAA]]'''<br>
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| :❑Contrast extravasation, draped aorta sign, and [[retroperitoneal]] [[hematoma]] with perirenal and pararenal space extension.<br>
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| ❑Emergency repair}}
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| {{familytree/end}}
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| Abdominal [[ultrasound|US]] (100% [[sensitivity|Sn]] and [[specificity|Sp]] but visualization among 1-3% [[patients]]). <ref name="urlAbdominal aortic aneurysm | Radiology Reference Article | Radiopaedia.org">{{cite web |url=https://radiopaedia.org/articles/abdominal-aortic-aneurysm#:~:text=CT%20angiography%20(CTA)%20is%20considered,arteries%20and%20the%20aortic%20bifurcation. |title=Abdominal aortic aneurysm | Radiology Reference Article | Radiopaedia.org |format= |work= |accessdate=}}</ref>
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| * AAAs are more likely to rupture in women than men.<ref name="urlwww.nice.org.uk">{{cite web |url=https://www.nice.org.uk/guidance/ng156/documents/short-version-of-draft-guideline |title=www.nice.org.uk |format= |work= |accessdate=}}</ref>
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| [[CT angiography]] (gold standard for evaluation of [[AAA]]).
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