Sandbox:Javaria: Difference between revisions
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:❑ [[Bloody stool]] | :❑ [[Bloody stool]] | ||
:❑ [[Weight loss]] | :❑ [[Weight loss]] | ||
:❑ [[Jaundice]] | :❑ [[Jaundice]] | ||
:❑ [[Fatigue]] | :❑ [[Fatigue]] | ||
:❑ Recent [[trauma]] | :❑ Recent [[trauma]] | ||
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'''Detailed history:'''<br> | '''Detailed history:'''<br> | ||
:❑ Age (Patients above 50 years old are more likely to have severe diseases or cancers, such as ruptured [[abdominal aortic aneurysm]] or [[colon cancer]]) | :❑ 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 | :❑ Past medical history ([[Hepatitis B|Hep B]], [[Hepatitis C|hep C]], [[NASH]], [[Alcoholic Hepatitis|alcoholic hep]] all predispose to [[HCC]]) | ||
:❑ Past surgical history (for previous abdominal surgeries) | :❑ Past surgical history (for previous abdominal surgeries) | ||
:❑ Menstrual and contraceptive history (pregnancy should be excluded in all women of childbearing age with abdominal mass) | :❑ 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 | :❑ Social history (alcohol abuse predispose to [[pancreatitis]] and [[hepatitis]], smoking also predisposes to [[AAA]] and [[cancer]]s, e.g. [[bladder cancer]]) | ||
:❑ Occupational history (exposure to chemicals or toxins) | :❑ Occupational history (exposure to chemicals or toxins) | ||
:❑ Travel history | :❑ Travel history (recent foreign travel/ drinking of unfiltered water increases risk for [[echinococcus]] or [[entamoeba]] infection). | ||
:❑ Medications ( | :❑ Family history ([[polycystic kidney disease]] | ||
:❑ Medications (30 and 50 years old women with longstanding [[OCP]] use, may suspect [[hepatic adenoma]]</div>}} | |||
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | |!| | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | A02 | | | | | | A02= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Examine the patient:''' <br> | {{familytree | | | | | | | | | | | | | | A02 | | | | | | A02= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Examine the patient:''' <br> | ||
❑ Vital signs<br> | ❑ Vital signs<br> | ||
:❑ [[Temperature]]<br> | :❑ [[Temperature]] ([[fever]] may point to [[abscess]] or other infectious causes of mass<br> | ||
:❑ [[Heart rate]] ([[tachycardia]]) <br> | :❑ [[Heart rate]] ([[tachycardia]]) <br> | ||
:❑ [[Blood pressure]] ([[hypotension]])<br> | :❑ [[Blood pressure]] ([[hypotension]])<br> | ||
Line 98: | Line 95: | ||
{{familytree/end}} | {{familytree/end}} | ||
Table illustrates common imaging findings | Table illustrates common imaging findings and management of stabke abdominal masses.<ref name="pmid10524843">{{cite journal |vauthors=Zhang Y, Uchida M, Abe T, Nishimura H, Hayabuchi N, Nakashima Y |title=Intrahepatic peripheral cholangiocarcinoma: comparison of dynamic CT and dynamic MRI |journal=J Comput Assist Tomogr |volume=23 |issue=5 |pages=670–7 |date=1999 |pmid=10524843 |doi=10.1097/00004728-199909000-00004 |url=}}</ref><ref name="pmid22895392">{{cite journal |vauthors=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 |title=Guidelines for the diagnosis and treatment of cholangiocarcinoma: an update |journal=Gut |volume=61 |issue=12 |pages=1657–69 |date=December 2012 |pmid=22895392 |doi=10.1136/gutjnl-2011-301748 |url=}}</ref><ref name="pmid28229074">{{cite journal |vauthors=Olthof SC, Othman A, Clasen S, Schraml C, Nikolaou K, Bongers M |title=Imaging of Cholangiocarcinoma |journal=Visc Med |volume=32 |issue=6 |pages=402–410 |date=December 2016 |pmid=28229074 |pmc=5290452 |doi=10.1159/000453009 |url=}}</ref> | ||
{| style="border: 2px solid #4479BA; align="left" | {| style="border: 2px solid #4479BA; align="left" | ||
! style="width: 100px; background: #4479BA;" | {{fontcolor|#FFF|Cause of abdominal mass}} | ! style="width: 100px; background: #4479BA;" | {{fontcolor|#FFF|Cause of abdominal mass}} | ||
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! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|'''MRI'''}} | ! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|'''MRI'''}} | ||
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|'''PET scan'''}} | ! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|'''PET scan'''}} | ||
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|'''Management'''}} | |||
|- | |- | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hepatic cyst]] | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hepatic cyst]] | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Reserved for more complicated cases. | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Reserved for more complicated cases. | ||
For more information [[Hepatic cysts|click here]] | For more information [[Hepatic cysts|click here]] | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Most useful initial test. | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
Assess cyst size, type, location within the liver, type, and anatomic relations with surroundings. | *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. | |||
| 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]] | |||
*[[Fever]] + [[cyst]]= suspect [[pyogenic liver abscess]]/ other infection. | |||
*An asymptomatic simple cyst does not require treatment. | |||
*Symptomatic cyst requires [[sclerotherapy]]/ wide unroofing surgery. | |||
*[[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) | |||
*Cystadenocarcinoma (hepatic lobectomy/ partial hepatectomy) | |||
|- | |- | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hemangioma]]s | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Hemangioma]]s | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Asymmetric peripheral enhancement on IV contrast (diagnostic potential) | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Asymmetric peripheral enhancement on IV contrast (diagnostic potential) | ||
| | | 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 | |||
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 | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Well-circumscribed hypo-intense lesions. | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Well-circumscribed hypo-intense lesions. | ||
| | | 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 | |||
[[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]] | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | With IV contrast, diffuse enhancement with arterial phase contrast, and then washout during delayed venous images. | ||
| | | 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;" | | |||
*Resection (small single lesions, no/limited cirrhosis)/ liver transplant (advanced [[cirrhosis]] but no extrahepatic disease. | |||
*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). | |||
*[[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]] | ||
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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;" | | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Reassurae and observe (no malignant potential) | |||
|- | |- | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Cholangiocarcinoma]] | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Cholangiocarcinoma]] | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Lesion occurs in the periphery of [[liver]] | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
Primary staging: Higher [[sensitivity|Sn]] in detecting extrahepatic invasion and vascular involvement. | *Lesion occurs in the periphery of [[liver]] | ||
*Primary staging: Higher [[sensitivity|Sn]] in detecting extrahepatic invasion and vascular involvement. | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Modality of choice for [[diagnosis]] and [[staging]] | |||
| 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;" | Surgical resection with negative margin. | ||
|- | |- | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Metastatsis | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Hypo-intense on venous phase contrast. CT does not reliably detect lesions smaller than 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;" | | |||
*[[PET scan]] is more [[sensitivity|Sn]] than CT for detecting hepatic metastases and can detect lesions < 1 cm. | |||
*Metastatic lesions appear as T1 weighted hypointense and T2 weighted hyper-intense images. | |||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
| | *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. | |||
|- | |||
| 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;" | | ||
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | | ||
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|- | |- | ||
|} | |} | ||
AFP level above 500 mg/dL should raise concern for the presence of HCC. |
Revision as of 19:07, 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:
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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 ❑ 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 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) | 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. |
| |||
Focal nodular hyperplasia | Well-circumscribed mass with central stellate scar. With IV contrast hyperintense on
arterial phase and isodense on venous phase. |
Reassurae and observe (no malignant potential) | |||
Cholangiocarcinoma | Modality of choice for diagnosis and staging | Surgical resection with negative margin. | |||
Metastatsis | Hypo-intense on venous phase contrast. CT does not reliably detect lesions smaller than 1 cm. |
| |||
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.