Sandbox:Javaria: Difference between revisions
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:❑ Radiation (eg, to the shoulder, back, flank, groin, or chest)<br> | :❑ Radiation (eg, to the shoulder, back, flank, groin, or chest)<br> | ||
'''Associated [[symptoms]]'''<br> | '''Associated [[symptoms]]'''<br> | ||
:❑ [[Shortness of breath]] | :❑ [[Shortness of breath]] (decreased oxygen carrying capacity due to splenic dysfunction) | ||
:❑ [[Altered mental status]] | :❑ [[Altered mental status]] | ||
:❑ [[Nausea]] & [[vomiting]] | :❑ [[Nausea]] & [[vomiting]] | ||
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:❑ [[Respiratory rate]] ([[tachypnea]])<br> | :❑ [[Respiratory rate]] ([[tachypnea]])<br> | ||
❑ Skin <br> | ❑ Skin <br> | ||
:❑ [[ | :❑ [[petechiae]]/[[ecchymoses]]/[[bleeding]] (may be associated with [[splenomegaly]] or [[hepatomegaly]] | ||
:❑ [[Pallor]] | :❑ [[Pallor]] | ||
:❑ [[Jaundice]] | :❑ [[Jaundice]] | ||
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{{familytree | | | | | | | | | | | | | | Z02 | | | | | | | | |Z02=<div style="float: left; text-align: left; line-height: 150% ">'''If the patient is unstable,''' <br> '''Stabilize the patient:'''<br> ❑ Establish two large-bore intravenous peripheral lines<br> ❑ [[NPO]] until the patient is stable<br> ❑ Supportive care (fluids and electrolyes as required)<br> ❑ Place nasogastric tube if there is bleeding, obstruction, significant [[nausea]] or [[vomiting]]<br> ❑ Place [[foley catheter]] to monitor volume status<br> ❑ Cardiac monitoring<br> ❑ Supplemental oxygen as needed<br> ❑ Administer early antibiotics if indicated </div>}} | {{familytree | | | | | | | | | | | | | | Z02 | | | | | | | | |Z02=<div style="float: left; text-align: left; line-height: 150% ">'''If the patient is unstable,''' <br> '''Stabilize the patient:'''<br> ❑ Establish two large-bore intravenous peripheral lines<br> ❑ [[NPO]] until the patient is stable<br> ❑ Supportive care (fluids and electrolyes as required)<br> ❑ Place nasogastric tube if there is bleeding, obstruction, significant [[nausea]] or [[vomiting]]<br> ❑ Place [[foley catheter]] to monitor volume status<br> ❑ Cardiac monitoring<br> ❑ Supplemental oxygen as needed<br> ❑ Administer early antibiotics if indicated </div>}} | ||
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | Z01 | | | | | | | | | | |Z01 =<div style="float: left; text-align: left; line-height: 150% ">'''If the patient is stable,'''<br> '''Order laboratory tests:'''<br> ❑ [[Pregnancy test]] (required in women of child-bearing age) <br>❑ [[CBC]], [[Hematocrit]]<br> ❑ [[Urinalysis]]<br> ❑[[ESR]]<br>❑ [[ABG]]<br> ❑ [[D dimer]]<br>❑ [[Serum lactate]]<br> ❑ [[BMP]] ([[urea]], [[creatinine]], [[serum electrolytes]], [[BSL]]) <br> ❑ [[Amylase]] <br> ❑ [[Lipase]] <br> ❑ [[Triglyceride]] <br>❑[[Liver function tests]] (total [[bilirubin]], direct [[bilirubin]], [[albumin]], [[AST]], [[ALT]], [[Alkaline phosphatase]], [[GGT]]) | {{familytree | | | | | | | | | | | | | | Z01 | | | | | | | | | | |Z01 =<div style="float: left; text-align: left; line-height: 150% ">'''If the patient is stable,'''<br> '''Order laboratory tests:'''<br> ❑ [[Pregnancy test]] (required in women of child-bearing age) <br> | ||
❑ [[CBC]], [[Hematocrit]] ([[thrombocytopenia]], [[leukopenia]], [[anemia]] may be associated with [[splenomegaly]])<br> | |||
❑ [[Urinalysis]]<br> ❑[[ESR]]<br>❑ [[ABG]]<br> ❑ [[D dimer]]<br>❑ [[Serum lactate]]<br> ❑ [[BMP]] ([[urea]], [[creatinine]], [[serum electrolytes]], [[BSL]]) <br> ❑ [[Amylase]] <br> ❑ [[Lipase]] <br> ❑ [[Triglyceride]] <br>❑[[Liver function tests]] (total [[bilirubin]], direct [[bilirubin]], [[albumin]], [[AST]], [[ALT]], [[Alkaline phosphatase]], [[GGT]]) | |||
---- | ---- | ||
'''Order imaging studies:''' <br> ❑ Order urgent trans abdominal [[ultrasound]] (TAUSG)<br> ❑ [[Abdominal CT]]<br> ❑ [[ECG]]<br> ❑ [[MRCP]] <br> ❑ [[Abdominal x-ray]] <br> ❑ [[Angiography]]<br> ❑ Diagnostic [[paracentesis]]<br> | '''Order imaging studies:''' <br> ❑ Order urgent trans abdominal [[ultrasound]] (TAUSG)<br> ❑ [[Abdominal CT]]<br> ❑ [[ECG]]<br> ❑ [[MRCP]] <br> ❑ [[Abdominal x-ray]] <br> ❑ [[Angiography]]<br> ❑ Diagnostic [[paracentesis]]<br> | ||
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! style="width: 100px; background: #4479BA;" | {{fontcolor|#FFF|Cause of abdominal mass}} | ! style="width: 100px; background: #4479BA;" | {{fontcolor|#FFF|Cause of abdominal mass}} | ||
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|'''CT scan'''}} | ! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|'''CT scan'''}} | ||
! style="width: | ! style="width: 100px; background: #4479BA;" | {{fontcolor|#FFF|'''Ultrasound'''}} | ||
! style="width: | ! style="width: 100px; background: #4479BA;" | {{fontcolor|#FFF|'''MRI'''}} | ||
! style="width: | ! style="width: 100px; background: #4479BA;" | {{fontcolor|#FFF|'''PET scan'''}} | ||
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|'''Management'''}} | ! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|'''Management'''}} | ||
|- | |- | ||
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| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
*Rule out [[infection]] and [[malignancy]] | *Rule out [[infection]] and [[malignancy]] before diagnosis. | ||
*[[Fever]] + [[cyst]]= suspect [[pyogenic liver abscess]]/ other infection. | *[[Fever]] + [[cyst]]= suspect [[pyogenic liver abscess]]/ other infection. | ||
* | *Asymptomatic simple cyst (no treatment required) | ||
*Symptomatic cyst | *Symptomatic cyst ([[sclerotherapy]]/ wide unroofing surgery). | ||
*[[Echinococcosis]] ([[anthelmintic]]s/ and surgery), [[amebic liver abscess]] ([[metronidazole]]), [[pyogenic liver abscess]] ([[Pyogenic liver abscess medical therapy|antibiotic]] + percutaneous drainage). | *[[Echinococcosis]] ([[anthelmintic]]s/ and surgery), [[amebic liver abscess]] ([[metronidazole]]), [[pyogenic liver abscess]] ([[Pyogenic liver abscess medical therapy|antibiotic]] + percutaneous drainage). | ||
*[[Cystadenoma]] (surgically removed/ partial hepatectomy) | *[[Cystadenoma]] (surgically removed/ partial hepatectomy) | ||
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| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;"| Biopsy is NOT recommended due to bleeding risk | | style="padding: 0 5px; background: #F5F5F5; text-align: left;"| | ||
Majority of patients do not require intervention. | *Biopsy is NOT recommended due to bleeding risk | ||
*Majority of [[patients]] do not require intervention. | |||
|- | |- | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hepatic adenoma]]s | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hepatic adenoma]]s | ||
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| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Malignant potential and bleeding risk | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
[[Discontinue|D/C]] [[OCP]] may lead to involution | *Malignant potential and bleeding risk. | ||
>4 cm [[hepatic adenoma|adenoma]] requires surgical resection. | *[[Discontinue|D/C]] [[OCP]] may lead to involution. | ||
*>4 cm [[hepatic adenoma|adenoma]] requires surgical resection. | |||
|- | |- | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hepatocellular carcinoma]] | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hepatocellular carcinoma]] | ||
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*If a [[patient]] with [[liver cirrhosis|cirrhosis]] presents with a >1cm liver mass, pursue a definitive diagnosis to rule out HCC. | *If a [[patient]] with [[liver cirrhosis|cirrhosis]] presents with a >1cm liver mass, pursue a definitive diagnosis to rule out HCC. | ||
*Non-surgical transarterial chemoembolization (TACE) and radiofrequency ablation (RFA). | *Non-surgical transarterial chemoembolization (TACE) and radiofrequency ablation (RFA). | ||
*[[Sorafenib]] (a [[tyrosine kinase inhibitor]] if patient is not a candidate for resection/ transplant. | *[[Sorafenib]] (a [[tyrosine kinase inhibitor]]) if patient is not a candidate for resection/ transplant. | ||
|- | |- | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Focal nodular hyperplasia]] | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Focal nodular hyperplasia]] | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Well-circumscribed mass with central stellate scar. | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Well-circumscribed mass with central stellate scar. Hyperintense on arterial phase and isodense on venous phase (IV contrast). | ||
arterial phase and isodense on venous phase. | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
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| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Surgical resection with negative margin. | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Surgical resection with negative margin. | ||
|- | |- | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Hepatic metastatsis | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Hypo-intense on venous phase contrast. | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Hypo-intense on venous phase contrast.Does not reliably detect lesions <1 cm. | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
* | *More [[sensitivity|Sn]] than CT and can detect lesions < 1 cm. | ||
* | *T1 weighted hypointense and T2 weighted hyper-intense images. | ||
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*Surgical resection of hepatic metastases after appropriate selection based on survival benefit. | *Surgical resection of hepatic metastases after appropriate selection based on survival benefit. | ||
*Radiofrequency ablation if hepatic resection is not possible. | *Radiofrequency ablation if hepatic resection is not possible. | ||
*A multidisciplinary approach is required. | *A multidisciplinary approach is required. | ||
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| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |[[Splenomegaly]] | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
*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. | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |Doppler can determine the splenic artery and splenic vein patency. | |||
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*Splenectomy relieves symptoms and induces hyposplenism. | |||
*[[Overwhelming post-splenectomy infection|OPSI]] is a life-threatening complication. | |||
*[[Overwhelming post-splenectomy infection|click here]] to read more. | |||
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Revision as of 20:04, 16 August 2020
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 symptoms
Detailed history:
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Examine the patient: ❑ Vital signs
❑ Skin
❑ Inspection
❑ Palpation
❑ Pelvic exam in females | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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 Order imaging studies: *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.[1][2][3]
Cause of abdominal mass | CT scan | Ultrasound | MRI | PET scan | Management |
---|---|---|---|---|---|
Hepatic cyst | Reserved for more complicated cases.
For more information click here |
|
| ||
Hemangiomas | Asymmetric peripheral enhancement on IV contrast (diagnostic potential) |
| |||
Hepatic adenomas | Well-circumscribed hypo-intense lesions. | ||||
Hepatocellular carcinoma | With IV contrast, diffuse enhancement with arterial phase contrast, and then washout during delayed venous images. |
| |||
Focal nodular hyperplasia | Well-circumscribed mass with central stellate scar. Hyperintense on arterial phase and isodense on venous phase (IV contrast). | Reassurae and observe (no malignant potential) | |||
Cholangiocarcinoma | 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. |
|
| ||
Splenomegaly |
|
Doppler can determine the splenic artery and splenic vein patency. |
| ||
AFP level above 500 mg/dL should raise concern for the presence of HCC.
- ↑ Zhang Y, Uchida M, Abe T, Nishimura H, Hayabuchi N, Nakashima Y (1999). "Intrahepatic peripheral cholangiocarcinoma: comparison of dynamic CT and dynamic MRI". J Comput Assist Tomogr. 23 (5): 670–7. doi:10.1097/00004728-199909000-00004. PMID 10524843.
- ↑ Khan SA, Davidson BR, Goldin RD, Heaton N, Karani J, Pereira SP, Rosenberg WM, Tait P, Taylor-Robinson SD, Thillainayagam AV, Thomas HC, Wasan H (December 2012). "Guidelines for the diagnosis and treatment of cholangiocarcinoma: an update". Gut. 61 (12): 1657–69. doi:10.1136/gutjnl-2011-301748. PMID 22895392.
- ↑ Olthof SC, Othman A, Clasen S, Schraml C, Nikolaou K, Bongers M (December 2016). "Imaging of Cholangiocarcinoma". Visc Med. 32 (6): 402–410. doi:10.1159/000453009. PMC 5290452. PMID 28229074.