Abdominal mass resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: , Javaria Anwer M.D.[2]
Synonyms and keywords: abdominal lump resident survival guide

Overview

An abdominal mass is a vast entity in oncology.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. The life-threatening causes of an abdominal mass include:

• Abdominal aortic aneurysm, specifically ruptured abdominal aortic aneurysm.
  • Tenth most common cause of death in the Western world.
  • Total mortality is estimated to be 80–90 %.
  • The 2013 mortality rate of US population above 44 years of age was 2.5 per 100,000. The incidence is on the decrease for the past two decades after a plateau. (the mortality rates act as a surrogate of incidence).
• Volvulus

Common Causes

Common causes of an abdominal mass described below follow a descending order. The list is based on a retrospective study from Turkey among 45 adult patients who underwent surgery because of an intra-abdominal mass (between May 2010 and May 2017).

Benign pathologies

• Mesenteric cyst
• Endometriosis
• Hydatid cyst
• Fibroma
• Dystrophic calcification
• Aberrant pancreas
• Leiomyoma
• Pseudocyst

Malignant pathologies

• Gastrointestinal stromal tumor (GIST)
• Liposarcoma
• Ovarian tumor
• Chondrosarcoma
• Neuroendocrine tumor
• Malignt mesenchymal tumor
• Lymphoma
• Schwannoma
• The following chart illustrates the probable causes of an abdominal mass based on the location and salient features.

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Causes of abdominal mass

Abdominal wall mass ❑Primary tumors (WHO classification) ❑Adipocytic tumors (lipoma, liposarcoma) ❑Fibroblastic/myofibroblastic tumors (desmoid tumor) ❑Nerve sheath tumors (schwannoma, neurofibroma) ❑Hemangiomas ❑Undifferentiated pleomorphic sarcomas ❑Metastasis ❑Tumor-like mass ❑Endometriosis, abscess, hematoma ❑Hernias (epigastric, umbilical, incisional, and spigelian)

Intra-abdominal/ retroperitoneal mass

Hepatic mass ❑Hepatitis (infectious, DILI, alcoholic, NASH, autoimmune, Wilson's disease ❑Storage diseases (glycogen storage disease, lysosomal storage disease, lipid storage disease, hemochromatosis) ❑Tumors ❑Primary Benign:adenoma, FNH ❑Primary malignant:HCC, cholangiocarcinoma ❑Metastatic: Hemangioma, lymphoma, myeloma and solid tumors. ❑Cholestasis (PBC, PSC)

Splenic mass ❑Infectious (IM, liver abscess, echinococcosis) ❑Myeloproliferative (lymphomas and leukemias) ❑Storage (Gaucher's, Niemann-Pick disease) ❑Infiltrative:amyloidosis, sarcoidosis ❑Miscellineous (PH, metastases (lung cancer or breast cancer, Felty's syndrome)

Gastrointestinal and Genitourinary mass ❑Gastrointestinal ❑Volvulus ❑IBD ❑Colon cancer ❑Gastric cancer ❑Cholecystitis ❑Genitourinary system ❑Bladder distension ❑Ovarian cyst/ ovarian cancer ❑Leiomyoma ❑Ureteropelvic junction obstruction/ urinomas ❑Testicular cancer

Pancreatic mass ❑Pancreatic cyst ❑Neoplastic (mucinous, serous, intraductal papillary, and solid pseudopapillary) ❑Non-neoplastic (true, mucinous) ❑Inflammatory (pseudocyst, acute fluid collection) ❑Solid: ❑Adenocarcinomas (ductal, bile duct, ampullar and duodenal) ❑Pancreatic neuroendocrine tumors ❑Others (lymphoma and metastasis)

Retroperitoneal mass

Neoplastic ❑Solid ❑Lymphoma ❑Hydronephrosis ❑Leiomyosarcoma ❑Germ cell tumors ❑Liposarcoma/ sarcoma ❑Renal cell carcinoma ❑Abdominal Aortic Aneurysm(AAA) ❑Cystic ❑Cystadenoma/ cystadenocarcinoma ❑Mature teratoma

Non-neoplastic ❑Solid ❑Extramedullary hematopoiesis ❑Retroperitoneal fibrosis ❑Erdheim-Chester disease ❑Cystic ❑Epidermoid cyst ❑Non-pancreatic pseudocyst ❑Lymphoceles, hematoma ❑Bronchogenic cyst

Diagnosis

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

Treatment

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

Do's

• Start the assessment of a patient with an abdominal mass using the pneumonic "ABC:" airway, breathing and circulation, to identify an unstable patient.
• Taking careful history, and thorough physical examination are crucial to creating narrow differential diagnoses.
• Among females of childbearing age (average age 12 and 51 or start of menstrual cycle till menopause), pregnancy screening (usually a urine pregnancy test) should be performed before diagnostic radiation exposure or interventions such as fluoroscopy‐guided interventions.
• Order an ultrasound or MRI among pregnant females to avoid exposure to radiation.
• Perform a pelvic and testicular examination among patients with lower abdominal pain.
• Correlate the CD4 count in HIV positive patients with the most commonly occurring pathology.
• Abdominal aortic aneurysm and malignancy are more important considerations among patients above 50 years of age than for younger patients.
• Suspect ruptured abdominal aortic aneurysm in old patients presenting with a pulsating mass, associated abdominal pain and a history of tobacco use.

Don'ts

• The content in this section is in bullet points.

References

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