Sandbox:Javaria

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

Patient presents with abdominal mass

No associated pain

Associated pain

Can be Hemangiomas, hepatic cyst, pancreatic cysts (also majority of cystic neoplasms), IPMN, pancreatic ductal adenocarcinoma (PDA), some neuroendocrine tumors, retroperitoneal sarcoma, lymphomas, testicular cancer, colon cancer hernias

Reducible mass ❑ Suspect hernia ❑ Aggravation on standing or cough and physical exam findings both lying down and standing support diagnosis

Abdominal US Elective repair

❑Characterise the mass ❑ Location ❑ Consistency (lipoma feels rubbery) ❑ Size, margins (malignant lesions have irregular, hard margins) ❑ Color, fluctuance. ❑Characterise the pain ❑ Site (eg, a particular quadrant or diffuse ❑ 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 (decreased oxygen carrying capacity due to splenic dysfunction) ❑ Weight loss, nausea & vomiting, anorexia, melena hematuria, jaundice, fatigue, diaphoresis, fever, 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 (Hep B, hep C, NASH, alcoholic hep all predispose to HCC) ❑ 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 AAA and cancers, e.g. bladder cancer) ❑ Occupational history (exposure to chemicals or toxins) ❑ Travel history (recent foreign travel/ drinking of unfiltered water increases risk for echinococcus or entamoeba infection). ❑ Family history (polycystic kidney disease ❑ Medications (30 and 50 years old women with longstanding OCP use, may suspect hepatic adenoma Anticoagulant use, suspect hematoma

Examine the patient: ❑ Vital signs ❑ Temperature (fever may point to abscess or other infectious causes of mass ❑ Heart rate (tachycardia) ❑ Blood pressure (hypotension) ❑ Respiratory rate (tachypnea) ❑ Skin ❑ petechiae/ecchymoses/bleeding (may be associated with splenomegaly or hepatomegaly ❑ Pallor (blood loss, hepatic or splenic pathology) ❑ Jaundice (hepatic or splenic pathology) ❑ Dehydration ❑ Inspection ❑ A patien lying still with bent knees,is suggestive of perforation and peritonitis (such as in volvulus) ❑ Surgical scars ❑ Abdominal pulsations ❑ Signs of systemic disease e.g. spider angiomata, suggestive of cirrhosis ❑ Auscultation ❑ Abdominal crepitations ❑ Reduced bowel sounds ❑ Bruit may suggest AAA ❑ Palpation ❑ Extreme pain may manifest as: rigidity and guarding ❑ Abdominal tenderness ❑ Distension ❑ Detection of masses on palpating the abdomen ❑ Pelvic exam in females / testicular examination in males ❑ Cardiovascular system ❑ Respiratory system ❑ Anorectal bleeding (maybe due to CRC or IBD) ❑ To read about signs of sepsis click here

Patient is unstable

Patient is stable

'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

Order laboratory tests: ❑ Pregnancy test (required in women of child-bearing age) ❑ CBC, Hematocrit (thrombocytopenia, leukopenia, anemia may be associated with splenomegaly) ❑ Urinalysis ❑ESR (infection, TB) ❑ ABG ❑ D dimer ❑ Serum lactate ❑ BMP (urea, creatinine, serum electrolytes, BSL) ❑ Amylase (important in pancreatic, hepatic, gastric pathologies) ❑ Lipase (important in pancreatic, hepatic, gastric pathologies) ❑ Triglyceride ❑Liver function tests (total bilirubin, direct bilirubin, albumin, AST, ALT, Alkaline phosphatase, GGT)

Abdominal x-ray (specially if suspecting bowel perforation) Ultrasound (TAUSG) is cases of emergency or routine

Strangulated hernia

Cholecystitis

No lesion demonstrated

Hematoma

Volvulus

Surgery

Conservative approach in acute cases (NPO, antibiotics, fluids or cholecystectomy

May require surgery

Emergency surgery

Abdominal CT/ MRI

Tumor

Incidentiloma

Bengn lesion

Malignant

❑24 hr urine/ plasma metanephrine/ catecholamines ❑Low-dose dexamethasone suppression test

Observe/ surgery

Surgery/ chemotherapy/ radiation

Non-functional

Functional

Surgery

<4cm Two CTs, 6 months apart, D/C follow-up if mass size remains constant

>4cm/ malignancy suspicion Observe if no suspicion of malignancy

MRCP
❑ Angiography