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

Abdominal 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 (decreased oxygen carrying capacity due to splenic dysfunction) ❑ Altered mental status ❑ Nausea & vomiting ❑ Diaphoresis ❑ Fever ❑ Hematuria ❑ Anorexia ❑ Bloody stool ❑ Weight loss ❑ Jaundice ❑ Fatigue ❑ 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

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 ❑ 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 e.g. ❑ Pallor, suggestive of bleeding ❑ Spider angiomata, suggestive of cirrhosis ❑ Auscultation ❑ Abdominal crepitations ❑ Reduced bowel sounds ❑ Bruit, suggestive of abdominal aortic aneurysm ❑ Palpation ❑ Rigidity ❑ Guarding ❑ Abdominal tenderness ❑ Distension ❑ Detection of masses on palpating the abdomen ❑ Carnett's sign ❑ 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, hypotension, decreased systemic vascular resistance, 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 (thrombocytopenia, leukopenia, anemia may be associated with splenomegaly) ❑ Urinalysis ❑ESR ❑ ABG ❑ D dimer ❑ Serum lactate ❑ BMP (urea, creatinine, serum electrolytes, BSL) ❑ Amylase ❑ Lipase ❑ Triglyceride ❑Liver function tests (total bilirubin, direct bilirubin, albumin, AST, ALT, Alkaline phosphatase, GGT) 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

Table illustrates common imaging findings and management of stabke abdominal masses.

Cause of abdominal mass	CT scan	Ultrasound	MRI	PET scan	Management
Hepatic cyst	Reserved for more complicated cases. For more information click here	Most useful initial test. Assess cyst size, type, location within the liver, type, and anatomic relations with surroundings. Follow-up with US only if cyst id >4 cm.			Rule out infection and malignancy before diagnosis. Fever + cyst= suspect pyogenic liver abscess/ other infection. Asymptomatic simple cyst: no treatment required. Symptomatic cyst: sclerotherapy/ wide unroofing surgery. Echinococcosis: anthelmintics/ and surgery), amebic liver abscess: metronidazole, pyogenic liver abscess: antibiotic + percutaneous drainage. Cystadenoma and cystadenocarcinoma: surgically removed/ lobectomy/partial hepatectomy.
Hemangiomas	Asymmetric peripheral enhancement on IV contrast (diagnostic potential)				Biopsy is NOT recommended due to bleeding risk Majority of patients do not require intervention.
Hepatic adenomas	Well-circumscribed hypo-intense lesions.				Malignant potential and bleeding risk. D/C OCP may lead to involution. >4 cm adenoma requires surgical resection.
Hepatocellular carcinoma	With IV contrast, diffuse enhancement with arterial phase contrast, and then washout during delayed venous images.				Resection (small single lesions, no/limited cirrhosis)/ liver transplant (advanced cirrhosis) but no extrahepatic disease. If a patient with cirrhosis presents with a >1cm liver mass, pursue a definitive diagnosis to rule out HCC. Non-surgical transarterial chemoembolization (TACE) and radiofrequency ablation (RFA). Sorafenib (tyrosine kinase inhibitor) if patient is not a candidate for resection/ transplant.
Focal nodular hyperplasia	Well-circumscribed mass with central stellate scar. Hyperintense on arterial phase and isodense on venous phase (IV contrast).				Reassure and observe (no malignant potential)
Cholangiocarcinoma	Lesion occurs in the periphery of liver Primary staging: Higher Sn in detecting extrahepatic invasion and vascular involvement.		Modality of choice for diagnosis and staging		Surgical resection with negative margin.
Hepatic metastatsis	Hypo-intense on venous phase contrast.Does not reliably detect lesions <1 cm.			More Sn than CT and can detect lesions < 1 cm. T1 weighted hypointense and T2 weighted hyper-intense images.	Surgical resection of hepatic metastases after appropriate selection based on survival benefit. Radiofrequency ablation if hepatic resection is not possible. A multidisciplinary approach is required.
Splenomegaly	Important in pre-operative planning for splenectomy via an open versus laparoscopic approach. CT volumetry measures the true size of an enlarged spleen, detects accessory splenic tissue.	Doppler can determine the splenic artery and splenic vein patency.			Splenectomy relieves symptoms and induces hyposplenism. OPSI is a life-threatening complication. click here to read more.
Cystic pancreatic mass	Serous cystic tumor: Hypervascular lesions with central scar, septations, and central/ sunburst calcification. Microcystic Honeycomb appearance. Intraductal papillary mucinous neoplasm (IPMN): Communicates with main- pancreatic duct, branch duct or both. Mucinous cystic neoplasm (MCN): Well encapsulated, circular, unilocular or septated cysts with wall calcifications. Solid pseudopapillary neoplasm (SPN): Large solid and cystic components, hemorrhage, necrosis and/without calcifications. A solid component in IPMN and MCN may suggest malignancy.				Esophageal US-guided FNA with cyst fluid analysis or ERCP for diagnosis. Non-neoplastic cysts and serous cystic tumor are removed only if symptomatic. IPMN communicating with the main duct/ symptomatic/ with malignancy suspician is resected. Other cases are monitored. MCN and SPN have a significant malignant potential and should be removed.
Solid pancreatic mass	Helps in diagnosis, staging, treatment planning and followup. 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 / CBD dilatation may be demonstrated. A “double-duct” sign may also be demonstrated. Acinar Cell Carcinoma (ACC): Solid or cystic mass is demonstrated. Pancreatic Neuroendocrine Tumors (PNET): CT must be obtained among all patients nonetheless. On IV contrast, hypervascular lesions on the arterial phase are demonstrated.	PDA:Endoscopic ultrasound (EUS)/ ERCP with tissue sampling are diagnostic tools. PNET: EUS > CT at locating the lesion and biopsy at the same time.	MRI can be utilised instead of CT.		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. ACC: Surgical resection. 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.
Retroperitoneal Sarcoma	Chest, abdomen and pelvis contrast-enhanced CT for diagnosis, staging, and ruling out metastatic disease.		MRI with gadolinium is an alternative in case of contrast allergy, pelvic involvement, and equivocal CT imaging findings.	Not routinely used.	Image-guided percutaneous core needle biopsy is considered safe and helps guide treatment modalities and the extent of surgery. R0 surgical resection is a potentially curative treatment method.
Hernias		First line imaging technique. Demonstration of bowel contents confims the disease.			Conservative approach/ elastic binders. Emergency surgery: abdominal contents compression/ strangulation. Elective surgery: Symptomatic hernia/ patient preference.

AFP level above 500 mg/dL should raise concern for the presence of HCC.