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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;">'''Abdominal 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]] (decreased oxygen carrying capacity due to splenic dysfunction)
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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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| :❑ [[Jaundice]]
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| :❑ [[Fatigue]]
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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 ([[Hepatitis B|Hep B]], [[Hepatitis C|hep C]], [[NASH]], [[Alcoholic Hepatitis|alcoholic hep]] all predispose to [[HCC]])
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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 [[AAA]] and [[cancer]]s, e.g. [[bladder cancer]])
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| :❑ Occupational history (exposure to chemicals or toxins)
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| :❑ Travel history (recent foreign travel/ drinking of unfiltered water increases risk for [[echinococcus]] or [[entamoeba]] infection).
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| :❑ Family history ([[polycystic kidney disease]]
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| :❑ Medications (30 and 50 years old women with longstanding [[OCP]] use, may suspect [[hepatic adenoma]]</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]] ([[fever]] may point to [[abscess]] or other infectious causes of mass<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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| :❑ [[petechiae]]/[[ecchymoses]]/[[bleeding]] (may be associated with [[splenomegaly]] or [[hepatomegaly]]
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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 e.g.<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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| :❑ 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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| ❑ [[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]], [[hypotension]], decreased [[systemic vascular resistance]], 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>
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| ❑ [[CBC]], [[Hematocrit]] ([[thrombocytopenia]], [[leukopenia]], [[anemia]] may be associated with [[splenomegaly]])<br>
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| ❑ [[Urinalysis]]<br> ❑[[ESR]]<br>❑ [[ABG]]<br> ❑ [[D dimer]]<br>❑ [[Serum lactate]]<br> ❑ [[BMP]] ([[urea]], [[creatinine]], [[serum electrolytes]], [[BSL]]) <br> ❑ [[Amylase]] <br> ❑ [[Lipase]] <br> ❑ [[Triglyceride]] <br>❑[[Liver function tests]] (total [[bilirubin]], direct [[bilirubin]], [[albumin]], [[AST]], [[ALT]], [[Alkaline phosphatase]], [[GGT]])
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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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|
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| Table illustrates common imaging findings and management of stabke abdominal masses.<ref name="pmid10524843">{{cite journal |vauthors=Zhang Y, Uchida M, Abe T, Nishimura H, Hayabuchi N, Nakashima Y |title=Intrahepatic peripheral cholangiocarcinoma: comparison of dynamic CT and dynamic MRI |journal=J Comput Assist Tomogr |volume=23 |issue=5 |pages=670–7 |date=1999 |pmid=10524843 |doi=10.1097/00004728-199909000-00004 |url=}}</ref><ref name="pmid22895392">{{cite journal |vauthors=Khan SA, Davidson BR, Goldin RD, Heaton N, Karani J, Pereira SP, Rosenberg WM, Tait P, Taylor-Robinson SD, Thillainayagam AV, Thomas HC, Wasan H |title=Guidelines for the diagnosis and treatment of cholangiocarcinoma: an update |journal=Gut |volume=61 |issue=12 |pages=1657–69 |date=December 2012 |pmid=22895392 |doi=10.1136/gutjnl-2011-301748 |url=}}</ref><ref name="pmid28229074">{{cite journal |vauthors=Olthof SC, Othman A, Clasen S, Schraml C, Nikolaou K, Bongers M |title=Imaging of Cholangiocarcinoma |journal=Visc Med |volume=32 |issue=6 |pages=402–410 |date=December 2016 |pmid=28229074 |pmc=5290452 |doi=10.1159/000453009 |url=}}</ref><ref name="pmid25960793">{{cite journal |vauthors=Pawlak M, Bury K, Śmietański M |title=The management of abdominal wall hernias - in search of consensus |journal=Wideochir Inne Tech Maloinwazyjne |volume=10 |issue=1 |pages=49–56 |date=April 2015 |pmid=25960793 |pmc=4414108 |doi=10.5114/wiitm.2015.49512 |url=}}</ref><ref name="pmid25383252">{{cite journal |vauthors=Becker LC, Kohlrieser DA |title=Conservative management of sports hernia in a professional golfer: a case report |journal=Int J Sports Phys Ther |volume=9 |issue=6 |pages=851–60 |date=November 2014 |pmid=25383252 |pmc=4223293 |doi= |url=}}</ref><ref name="pmid26739977">{{cite journal |vauthors=Zhang HY, Liu D, Tang H, Sun SJ, Ai SM, Yang WQ, Jiang DP, Zhang LY |title=The effect of different types of abdominal binders on intra-abdominal pressure |journal=Saudi Med J |volume=37 |issue=1 |pages=66–72 |date=January 2016 |pmid=26739977 |pmc=4724682 |doi=10.15537/smj.2016.1.12865 |url=}}</ref>
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| {| style="border: 2px solid #4479BA; align="left"
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| ! style="width: 100px; background: #4479BA;" | {{fontcolor|#FFF|Cause of abdominal mass}}
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| ! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|'''CT scan'''}}
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| ! style="width: 70px; background: #4479BA;" | {{fontcolor|#FFF|'''Ultrasound'''}}
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| ! style="width: 100px; background: #4479BA;" | {{fontcolor|#FFF|'''MRI'''}}
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| ! style="width: 70px; background: #4479BA;" | {{fontcolor|#FFF|'''PET scan'''}}
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| ! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|'''Management'''}}
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hepatic cyst]]
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Reserved for more complicated cases.
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| For more information [[Hepatic cysts|click here]]
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *Most useful initial test.
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| *Assess cyst size, type, location within the liver, type, and anatomic relations with surroundings.
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| *Follow-up with [[US]] only if cyst id >4 cm.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *Rule out [[infection]] and [[malignancy]] before diagnosis.
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| *[[Fever]] + [[cyst]]= suspect [[pyogenic liver abscess]]/ other infection.
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| *Asymptomatic simple cyst: no treatment required.
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| *Symptomatic cyst: [[sclerotherapy]]/ wide unroofing surgery.
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| *[[Echinococcosis]]: [[anthelmintic]]s/ and surgery), [[amebic liver abscess]]: [[metronidazole]], [[pyogenic liver abscess]]: [[Pyogenic liver abscess medical therapy|antibiotic]] + percutaneous drainage.
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| *[[Cystadenoma]] and cystadenocarcinoma: surgically removed/ lobectomy/partial hepatectomy.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hemangioma]]s
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Asymmetric peripheral enhancement on IV contrast (diagnostic potential)
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;"|
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| *Biopsy is NOT recommended due to bleeding risk
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| *Majority of [[patients]] do not require intervention.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hepatic adenoma]]s
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Well-circumscribed hypo-intense lesions.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *Malignant potential and bleeding risk.
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| *[[Discontinue|D/C]] [[OCP]] may lead to involution.
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| *>4 cm [[hepatic adenoma|adenoma]] requires surgical resection.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hepatocellular carcinoma]]
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | With IV contrast, diffuse enhancement with arterial phase contrast, and then washout during delayed venous images.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *Resection (small single lesions, no/limited cirrhosis)/ liver transplant (advanced [[cirrhosis]]) but no extrahepatic disease.
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| *If a [[patient]] with [[liver cirrhosis|cirrhosis]] presents with a >1cm liver mass, pursue a definitive diagnosis to rule out HCC.
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| *Non-surgical transarterial chemoembolization (TACE) and radiofrequency ablation (RFA).
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| *[[Sorafenib]] ([[tyrosine kinase inhibitor]]) if patient is not a candidate for resection/ transplant.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Focal nodular hyperplasia]]
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Well-circumscribed mass with central stellate scar. Hyperintense on arterial phase and isodense on venous phase (IV contrast).
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Reassure and observe (no malignant potential)
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Cholangiocarcinoma]]
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *Lesion occurs in the periphery of [[liver]]
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| *Primary staging: Higher [[sensitivity|Sn]] in detecting extrahepatic invasion and vascular involvement.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Modality of choice for [[diagnosis]] and [[staging]]
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Surgical resection with negative margin.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Hepatic metastatsis
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Hypo-intense on venous phase contrast.Does not reliably detect lesions <1 cm.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *More [[sensitivity|Sn]] than CT and can detect lesions < 1 cm.
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| *T1 weighted hypointense and T2 weighted hyper-intense images.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *Surgical resection of hepatic metastases after appropriate selection based on survival benefit.
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| *Radiofrequency ablation if hepatic resection is not possible.
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| *A multidisciplinary approach is required.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Splenomegaly]]
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *Important in pre-operative planning for [[splenectomy]] via an open versus laparoscopic approach.
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| *CT volumetry measures the true size of an enlarged spleen, detects accessory splenic tissue.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Doppler can determine the splenic artery and splenic vein patency.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *Splenectomy relieves symptoms and induces hyposplenism.
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| *[[Overwhelming post-splenectomy infection|OPSI]] is a life-threatening complication.
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| *[[Overwhelming post-splenectomy infection|click here]] to read more.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Cystic [[pancreas|pancreatic]] mass
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *Serous cystic tumor: Hypervascular lesions with central scar, septations, and central/ sunburst calcification. Microcystic ''Honeycomb'' appearance.
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| *Intraductal papillary mucinous neoplasm (IPMN): Communicates with main- pancreatic duct, branch duct or both.
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| *Mucinous cystic neoplasm (MCN): Well encapsulated, circular, unilocular or septated cysts with wall calcifications.
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| *Solid pseudopapillary neoplasm (SPN): Large solid and cystic components, [[hemorrhage]], [[necrosis]] and/without [[calcifications]].
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| *A solid component in IPMN and MCN may suggest malignancy.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *Esophageal [[US]]-guided [[Needle aspiration biopsy|FNA]] with cyst fluid analysis or [[ERCP]] for diagnosis.
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| *Non-neoplastic cysts and serous cystic tumor are removed only if symptomatic.
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| *IPMN communicating with the main duct/ symptomatic/ with malignancy suspician is resected. Other cases are monitored.
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| *MCN and SPN have a significant malignant potential and should be removed.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Solid [[pancreas|pancreatic]] mass
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *Helps in diagnosis, staging, treatment planning and followup.
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| *Pancreatic Ductal Adenocarcinoma (PDA): CT with IV contrast is the initial test of choice. A hypodense lesion that disrupting normal architecture of the [[pancreas]] accompanied by pancreatic / [[common bile duct|CBD]] dilatation may be demonstrated. A “double-duct” sign may also be demonstrated.
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| *Acinar Cell Carcinoma (ACC): Solid or cystic mass is demonstrated.
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| *Pancreatic Neuroendocrine Tumors (PNET): CT must be obtained among all patients nonetheless. On IV contrast, hypervascular lesions on the arterial phase are demonstrated.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *PDA:Endoscopic ultrasound (EUS)/ [[endoscopic retrograde cholangiopancreatography|ERCP]] with tissue sampling are diagnostic tools.
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| *PNET: EUS > CT at locating the lesion and biopsy at the same time.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |MRI can be utilised instead of CT.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *PDA: Resectable pancreatic head PDA us treated with pancreaticoduodenectomy ([[Whipple procedure]]). For the body and tail distal pancreatectomy is performed. [[Chemotherapy]] and [[radiotherapy]] are administered and/or post surgery.
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| *ACC: Surgical resection.
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| *PNET: Serum hormone testing is the mainstay of management. Surgical resection is the primary method of treatment as majority of tumors have malignant potential. Additional medical therapy may be required.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Retroperitoneal Sarcoma
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Chest, abdomen and pelvis contrast-enhanced CT for diagnosis, staging, and ruling out metastatic disease.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |MRI with gadolinium is an alternative in case of contrast allergy, pelvic involvement, and equivocal CT imaging findings.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Not routinely used.
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| *Image-guided percutaneous core needle biopsy is considered safe and helps guide treatment modalities and the extent of surgery.
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| *R0 surgical resection is a potentially curative treatment method.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Hernia]]s
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |First line imaging technique. Demonstration of bowel contents confims the disease.
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
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| *Conservative approach/ elastic binders.
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| *Emergency surgery: abdominal contents compression/ strangulation.
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| *Elective surgery: Symptomatic hernia/ patient preference.
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| |-
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| |}
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| AFP level above 500 mg/dL should raise concern for the presence of HCC.
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