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

Abdominal mass

History and brief physical exam Past medical history

Hemodynamic instability

Stable

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Abdominal mass

Groin mass Inguinal hernia, femoral hernia, reactive or malignant adenopathy, iliac or femoral aneurysm or pseudoaneurysm, Sebaceous cyst, hidradenitis, lipoma, epididymitis, testicular torsion, varicocele, hydrocele, ectopic testicle, and undescended testicle

Abdominal wall mass epigastric hernia, umbilical hernia, incisional hernia, diastasis recti, rectus sheath hematoma, spigelian hernia, desmoid tumor, and intra-abdominal pathology.

Intra-abdominal/ retroperitoneal mass

Hepatic mass

Splenic mass

Pancreatic mass

Retroperitoneal mass

Aortic aneurysm

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

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