Approach to a patient with abdominal lump

Epigastric region

• Structures-liver and subphrenic abscess, stomach, duodenum, transverse colon, omentum, pancreas, abdominal aorta, LN.
  • Congenital Hypertrophic pyloric stenosis
  • Gastric torsion
  • Pseudo pancreatic cyst, pancreatic abscess
  • Hepatomegaly
  • Gastroparesis
  • Intussusception
  • Duplication of stomach/duodenum

Right Hypochondrium

• Structures– liver, gallbladder, subphrenic space, hepatic flexure of the colon, rt. Kidney and suprarenal glands.
  • Hepatomegaly
  • Choledochal cyst
  • Subphrenic abscesses
  • Kidney swelling

Causes of Hepatomegaly

Infections

• Viral– congenital rubella, CMV, hepatitis infection, infectious mononucleosis, viral infection, HIV
• Bacterial– septicaemia, tuberculosis, congenital syphilis, pyogenic liver abscess.
• Parasitic infections- hydatid cyst, toxoplasmosis, amoebic liver abscess, malaria & kala-azar.

Hematological/ Reticuloendothelial

• Thalassemia, sickle cell disease, ALL, AML, CML.
• Non- Hodgkin lymphoma, Hodgkin disease.

Congestive

• CCF, constrictive pericarditis, Pericardial effusion, Budd Chiari syndrome, the venous-occlusive disease of the liver.

Infiltrative

• Histiocytosis
• sarcoidosis

Structural/Metabolic

• Sphingolipidoses – Gaucher disease, Niemann-Pick disease
• Mucolipidoses, Mucopolysaccharidosis
• GSD (type 1,3,4,6), Galactosemia
• Tyrosinaemia type I, UreaCycle enzyme disorders.
• Wilson disease
• Cystic fibrosis
• Alpha- 1- antitrypsin deficiency
• Hyperlipoproteinemias
• PEM

Connective tissue disorder

• Systemic JRA, SLE

Tumor/hamartoma

• Primary hepatic neoplasms: hepatoblastoma, hepatocellular carcinoma
• Vascular tumors in the liver
• Secondary deposits: neuroblastoma, Wilm’s tumor, gonadal tumors.

Trauma
Hepatic hematoma
Drugs
Tetracycline toxicity

Left Hypochondrium

• Structures– spleen, stomach, left lobe of the liver, splenic flexure of the colon, the tail of the pancreas, lt kidney and suprarenal gland.
  • Splenomegaly
  • Enlarged Kidney

Cause of splenomegaly

• Infection
  • Viral – infectious mononucleosis, CMV, HIV
  • Bacterial – Subacute bacterial endocarditis, typhoid, septicemia, tuberculosis, brucellosis
  • Protozoal infection – malaria, kala-azar, toxoplasmosis.
• Hematological
  • Chronic hemolytic anemias
• Connective tissue disease
  • Systemic JRA, SLE, Felty’s synd, Behcet’s disease, Sjogren’s syndrome
• Portal hypertension
  • Extrahepatic- postneonatal umbilical vessel catheterization or sepsis, Budd- Chiari syndrome
  • Hepatic- cirrhosis (post viral, autoimmune hepatitis, Wilson’s disease, other metabolic causes)
• Sarcoidosis
• Hypereosinophilic syndrome
• Malignancy
  • Leukaemia, Lymphoma
• Storage diseases
  • Gaucher’s, Niemann- Pick disease
• Splenic cyst, tumor, abscess or hamartoma
• Injury – Splenic Hematoma

Right/Left Lumbar region

• Structures- kidney, ascending & descending colon.

Unilateral flank mass

• Tumor

Renal- Wilms tumor, renal cell carcinoma, Congenital mesoblastic nephroma.
Non renal- Neuroblastoma, Adrenal cell carcinoma, Pheochromocytoma

• Hydronephrosis
• Hypertrophied solitary kidney.
• Renal cyst.
• Renal vein thrombosis.
• Perinephric abscess

Bilateral flank mass

• Polycystic kidney disease
• Hydronephrosis- PUV, VUR, neurogenic bladder, phimosis, meatal stenosis, urethral stone.
• Tumor- Wilms, leukemia, lymphoma, tuberous sclerosis.
• Metabolic – GSD type 1, Tyrosinemia type 1

Umbilical region

• Intussusception
• Volvulus
• Duplication of the small intestine
• Mesenteric/Omental cyst
• Matted coils of intestines with tuberculous mesenteric lymphadenitis
• Lymphoma, Teratoma
• Toxic megacolon

Right iliac fossa

• Structures– appendix, caecum, terminal ileum, LN, tubes & ovary.
• Appendicular mass, abscess, tumor
• Hyperplastic ileocaecal TB
• Impaction of roundworms in the ileum, rarely trichobezoar.
• Iliac abscess, iliopsoas abscess
• Tubo-ovarian mass, Dermoid, Torsion of the ovary, Follicular cyst.
• Unascended kidney
• Undescended testis

Left iliac fossa

• Structures – sigmoid colon, tubes & Ovary
• Feces – constipation

Hypogastrium

• Structures– urinary bladder, sigmoid colon, uterus, and its appendages.
  • Distended urinary bladder
  • Gravid uterus
  • Pelvic abscess
• lumps in parietal wall
  • Umbilical, epigastric, inguinal, femoral hernia
  • Umbilical granuloma
  • Congenital polyp or adenoma arising from patent vitelline duct.
  • Omphalocele/,Gastroschisis
  • Trauma (rectus hematoma)
  • Cysts (sebaceous cyst)
  • Tumor (fibroma, lipoma, rhabdomyosarcoma)
  • Urachal cyst in hypogastrium
  • Parietal wall abscess

APPROACH

• With all abdominal masses, an assessment of the child’s age and clinical state is important in determining the diagnosis.

Abdominal masses in the newborn:

1. Renal masses (55%): hydronephrosis, multicystic dysplastic kidney, polycystic kidney, Mesoblastic nephroma/Wilm’s tumor, renal vein thrombosis, renal ectopia
2. Genital masses (15%): hydrometrocolpos, ovarian cyst
3. GI masses (15%): duplications, obstruction, mesenteric/omental cyst, splenic hematoma/cyst, meconium peritonitis
4. Hepatobiliary (5%): liver cyst, liver tumor, choledochal cyst, hydrops of gall bladder, neuroblastoma (metastasis)
5. Retroperitoneal masses (5%): lymphangioma, extra-adrenal neuroblastoma, anterior meningocele, teratoma, rhabdomyosarcoma
6. Adrenal masses (5%): neuroblastoma, adrenal hemorrhage

History

• Age – intussusception
• Sex – for X- linked diseases
• Residence – Malaria, Kala-azar
• Duration – recent or chronic
• Fever – hepatitis, infectious mononucleosis, TB, malaria, kala-azar
• Vomiting – hepatitis, Hypertrophic pyloric stenosis, meconium peritonitis
• Jaundice – EHBA, hepatitis
• Increasing pallor – chronic hemolytic anemia, malignancy
• Abdominal pain – sickle cell anemia
• Rashes – SLE, systemic onset JRA
• Seizure – Inborn error of metabolism
• Shortness of breath – CCF
• H/o recent weight loss – Malignancy
• H/o failure to thrive – Chronic liver/kidney disease
• Swelling of abdomen/body – cirrhosis, CCF
• Bony tenderness- leukemia
• Frequency and quality of bowel habit: red currant jelly-intussusception, whitish stool – EHBA
• Hematuria or dysuria – renal disease
• Retention of urine with H/O straining – PUV
• H/O abdominal trauma – hematoma, pseudopancreatic cyst
• H/O mental retardation – galactosemia
• Past history – jaundice
• H/O frequent chest infection – Cystic fibrosis, Alpha-1 antitrypsin deficiency, GSD 2.
• H/o blood transfusion in past – hemolytic disease, hepatitis B, C
• Contact history – Tuberculosis
• H/O similar problem in siblings – storage diseases
• H/o consanguinity – Thalassemia
• Drug history – drug-induced hepatitis

Physical Examination

• Vitals – temp, blood pressure
• Anthropometry
• Microcephaly- rubella
• Macrocephaly with hydrocephalus – toxoplasmosis
• Icterus- liver diseases, hemolytic anemia
• Pallor – Hemolytic anemia, leukemia
• Clubbing- Crohn’s disease, SBE
• Lymphadenopathy- TB, HIV, CMV infection Infectious mononucleosis, Leukemias, lymphomas
• Pedal edema- CCF, Chronic liver diseases, liver failure.
• JVP – raised in CCF, pericardial effusion, constrictive pericarditis.
• Peripheral stigmata of CLD – bruising, spider naevi
• Facial characteristic
• Thalassemic face
• Cushingoid face (adrenal tumor, during Rx of nephrotic),
• Coarse face ( Mucopolysaccharidosis, Hypothyroidism)
• Mouth
• Palatal petechiae, Gum bleeding
• Oral ulcers
• Eye
• Xanthelasma – hyperlipoproteinemias
• Aniridia- Wilm’s tumor
• proptosis –neuroblastoma
• Kayser- Fleischer ring in cornea- Wilson’s disease
• Xerosis – Sjogren’s syndrome
• Corneal clouding- MPS IH & IS
• Cataract –Galactosaemia, toxoplasmosis, CMV, Rubella infections
• Uveitis- Pauciarticular JRA, TB, Sarcoidosis, Behcet’s disease
• Chorioretinitis – CMV, Toxoplasmosis
• Cherry red spot- Niemann-pick disease
• Macroglossia – Mucopolysaccharidoses, Hypothyroidism
• Deafness- TORCH
• Skin rashes, petechiae – leukemias
• Joint swelling/ arthritis – SLE, JRA, Behcet’s disease, Sjogren’s syndrome
• Skeletal changes of rickets- tyrosinosis, cystinosis
• Bony tenderness in leukemias
• CVS
• Evidence of congenital heart disease – TORCH infection
• Hepatomegaly, tachypnoea, tachycardia, raised JVP, mild icterus in CCF, Pericardial diseases.
• CHEST
• For signs of infection- Cystic fibrosis, alpha1 antitrypsin deficiency presents with frequent infections.
• Pigeon chest- tyrosinosis
• CNS
• Alertness – TORCH, Hypothyroidism
• Choreoathetosis movements- Wilson
• Pathological persistence of primitive reflexes- TORCH
• Hemihypertrophy
• Wilm’s tumor, hepatoblastoma

Abdominal Examination

Inspection

• Position, Size & Shape
• The condition of skin over the swelling
• Movement with respiration/ other direction
• Visible peristalsis
• Hernial sites
• Scrotum

Palpation

• Local Temperature
• Tenderness
• Position, size, shape, and surface
• Margin
• Consistency
• Movement
• Parietal or intraabdominal
• Is the swelling pulsatile or not
• Hernial site and per rectal examination

Percussion

• Solid organ – dull ( liver, spleen, solid tumor)
• Coils of the intestine- resonant
• Kidney swelling will have a band of resonance unless kidney is very much enlarged.
• Loin percussion just lateral to the lateral border of erector spinae- dull in kidney swellings.
• Shifting dullness

Auscultation

Investigation

• USG abdomen/ doppler – most useful, the primary imaging modality in the abdominal lump. -Neuroblastoma often contains calcium and encases the major abdominal vessels.
  -Wilm’s tumor displaces the central vessels and rarely calcifies.
• Abdominal Xray – obstruction, perforation.
• Barium swallow/ enema/ follow through
• Nuclear scintigraphy, CT and MRI are used for malignant or complicated cases
• HIDA scan
• Intravenous urography
• ECHO
• CBC, Peripheral smear, ESR – Infections
• Reticulocyte count, RBC indices G6PD, Sickling, Osmotic fragility test – in susp[icion of hemolytic anemia
• Mantoux test
• Biochemistry – depending on clinical suspicion. RBS, electrolytes, LFT, RFT.
• Serology: Viral markers, HBsAg test, HIV test, TORCH titer.
• Microscopy, culture/sensitivity
• Urinary copper excretion.
• Metabolic screening
• Stool examination: for ova, parasites, occult blood.
• Esophagogastroduodenoscopy, colonoscopy, sigmoidoscopy.
• Tissue biopsy – LN, mass
• Bone marrow biopsy- leukemia, Kala-azar.
• Laparoscopy – direct intraperitoneal visualization and biopsy of tissue, also helpful in the staging of the tumor.

Management

• First, we have to evaluate the clinical state of the patient for management
• Managed according to the cause.