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

{{{ ! }}}

{{{ ! }}}

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) and physical exam (such as location and extent of the mass, change in size) Risk factors for the development of 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)

Emergency repair (open or endovascular) if expertise are available

Transfer to a facility with vascular specialist expertise

No AAA

AAA found

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

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

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

Pain 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

❑Unruptured AAA ❑Hyperattenuating crescent sign, >150% normal diameter of aorta, mural thrombus and calcification ❑Moderate risk, 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).