Sandbox:Javaria

Shown below is an algorithm summarizing the diagnosis of abdominal mass according the the [...] guidelines.

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

Abdominal mass

History and brief physical exam Past medical history

Hemodynamic instability

Stable

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Characterize the mass: ❑Pulsatile mass ❑Constant mass Associated pain: ❑ Site (eg, a particular quadrant or diffuse, a change in location may reflect progression of the disease ❑ Onset (eg, sudden, gradual) ❑ Quality (eg, dull, sharp, colicky, waxing and waning) ❑ Aggravating and relieving factors (e.g, Is the pain related to your meals?) ❑ Intensity (scale of 0-10/ 0-5 with the maximum number; 10/5 being the worst pain of life) ❑ Time course (eg, hours versus weeks, constant or intermittent) ❑ Radiation (eg, to the shoulder, back, flank, groin, or chest) Associated symptoms ❑ Shortness of breath ❑ Altered mental status ❑ Nausea & vomiting ❑ Diaphoresis ❑ Fever ❑ Hematuria ❑ Anorexia ❑ Bloody stool ❑ Weight loss ❑ Vaginal discharge ❑ Penile discharge ❑ Jaundice ❑ Mal-digestion ❑ Flatulence ❑ Fatigue ❑ Scrotal pain/swelling ❑ Recent trauma ❑ Symptoms suggestive of sepsis Detailed history: ❑ Age (Patients above 50 years old are more likely to have severe diseases or cancers, such as ruptured abdominal aortic aneurysm or colon cancer) ❑ Past medical history (to exclude risk factors for cardiovascular diseases or peripheral vascular disease) ❑ Past surgical history (for previous abdominal surgeries) ❑ Menstrual and contraceptive history (pregnancy should be excluded in all women of childbearing age with abdominal mass) ❑ 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) ❑ Occupational history (exposure to chemicals or toxins) ❑ Travel history ❑ Medications (for over the counter drugs as

Examine the patient: ❑ Vital signs ❑ Temperature ❑ Heart rate (tachycardia) ❑ Blood pressure (hypotension) ❑ Respiratory rate (tachypnea) ❑ Skin ❑ Diaphoresis ❑ Pallor ❑ Jaundice ❑ Dehydration ❑ Inspection ❑ If the patient is lying still in bed with knees bent, this is suggestive of organ rupture and resulting peritonitis ❑ Signs of previous surgery ❑ Abdominal pulsations ❑ Signs of systemic disease eg, ❑ Pallor, suggestive of bleeding ❑ Spider angiomata, suggestive of cirrhosis ❑ Auscultation ❑ Abdominal crepitations ❑ Reduced bowel sounds ❑ Increased bowel sounds ❑ Bruit, suggestive of abdominal aortic aneurysm ❑ Palpation ❑ Rigidity ❑ Guarding ❑ Abdominal tenderness ❑ Distension ❑ Detection of masses on palpating the abdomen ❑ Carnett's sign ❑ Psoas sign (suggestive of retrocecal appendix) ❑ Cullen's sign ❑ Grey-Turner's sign ❑ Digital rectal exam (tenderness may be present in retrocecal appendicitis) ❑ Pelvic exam in females ❑ Testicular examination in males ❑ Cardiovascular system ❑ Respiratory system ❑ Anorectal (bleeding) ❑ 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

Consider extraabdominal differential diagnosis: ❑ aaaa

❑ Assess hemodynamic stability

If the patient is unstable, Stabilize the patient: ❑ Establish two large-bore intravenous peripheral lines ❑ NPO until the patient is stable ❑ Supportive care (fluids and electrolyes as required) ❑ Place nasogastric tube if there is bleeding, obstruction, significant nausea or vomiting ❑ Place foley catheter to monitor volume status ❑ Cardiac monitoring ❑ Supplemental oxygen as needed ❑ Administer early antibiotics if indicated

If the patient is stable, Order laboratory tests: ❑ Pregnancy test (required in women of child-bearing age) ❑ CBC ❑ Hematocrit ❑ Urinalysis ❑ Serum electrolytes ❑ ESR ❑ ABG ❑ D dimer ❑ Serum lactate ❑ BUN ❑ Creatinine ❑ Amylase ❑ Lipase ❑ Triglyceride ❑ Total bilirubin ❑ Direct bilirubin ❑ Albumin ❑ AST ❑ ALT ❑ Alkaline phosphatase ❑ GGT ❑ Stool for ova and parasites ❑ C. difficile culture and toxin assay Order imaging studies: ❑ Order urgent trans abdominal ultrasound (TAUSG) ❑ Abdominal CT ❑ ECG ❑ MRCP ❑ Abdominal x-ray ❑ Angiography ❑ Diagnostic paracentesis *Order the tests to rule in a suspected diagnosis or to assess a case of unclear etiology *In case of elderly patients, immunocompromised or those unable to provide a comprehensive history, order broader range of tests

Signs of peritonitis or shock ❑ Fever ❑ Abdominal tenderness ❑ Abdominal gaurding ❑ Rebound tenderness (blumberg sign) ❑ Diffuse abdominal rigidity ❑ Confusion ❑ Weakness ❑ Low blood pressure ❑ Decreased urine output ❑ Tachycardia

No

Yes

Pulsatile abdominal mass ❑History (such as associated pain, past medical, surgical history) ❑Physical exam (such as location and extent of the mass, change in size) ❑Risk factors for the development of Abdominal AOrtic Aneurysm (AAA)

Assess hemodynamic stability

Unsable

Stable

❑Airway, Breathing and Circulation (ABC) ❑Clinical diagnosis of ruptured AAA considered if patient is/was a smoker, >60 years old, HTN history, an existing diagnosis of AAA, and abdominal/back pain. ❑Immediate bedside aortic US ❑Systolic BP >70 acceptable (permissive hypotension)

❑Abdominal ultrasound scan (US) ❑Abdominal US (100% Sn and Sp but visualization among 1-3% patients) ❑CTA serves as first line modality to assess AAA in few cases

Emergency repair (open or endovascular) if expertise are available

Transfer to a facility with vascular specialist expertise

AAA not demonstrated

AAA demonstrated

Look for other possible causes on a CT scan ❑Heart failure (hepatomegaly, portal hypertension, pulmonary edema, and contrast reflux into IVC and hepatic veins) ❑Colonic diverticula with peri-colic inflammation and fluid collection ❑Dilatation of renal pelvicalyceal systems, splenomegaly ❑Tumors (distinct mass or diffuse organ infiltration, LAD, metastasis to other organs) ❑Pancreatic pseudocyst (Large cyst/multiple cysts in and around the pancreas with calcifications maybe, splenic vein thrombosis, and pseudoaneurysms of splenic artery, bleeding into a pseudocyst

<5.5cm

≥5.5cm

No pain demonstrated Rupture risk<operative repair risk (1 year)

Pain is present Search for risk factors: female, smoker, height, age, HTN history or other causes

No Pain demonstrated Rupture risk>operative repair risk (1 year) Elective repair considered

Pain is present High rupture risk

Other causes (low rupture risk)

No other causes (moderate-high risk of rupture)

❑RFTs ❑Crt<2mg/dl=CTA ❑Crt>2mg/dl or dye allergy=MRA

❑Follow-up in 6M ❑Repair of aneurysm if it grows >0.4cm/year or becomes symptomatic ❑Patient education

❑Unruptured AAA (moderate risk) ❑Hyperattenuating crescent sign, >150% normal diameter of aorta, mural thrombus and calcification ❑Consider elective repair

❑Ruptured AAA ❑Contrast extravasation, draped aorta sign, and retroperitoneal hematoma with perirenal and pararenal space extension. ❑Emergency repair

Abdominal US (100% Sn and Sp but visualization among 1-3% patients).

• AAAs are more likely to rupture in women than men.

CT angiography (gold standard for evaluation of AAA).