Sandbox:Javaria
Shown below is an algorithm summarizing the diagnosis of abdominal mass according the the [...] guidelines.
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 | |||||||||||||||||||||||
History and brief physical exam Past medical history | |||||||||||||||||||||||
Hemodynamic instability | Stable | ||||||||||||||||||||||
{{{ ! }}} | {{{ ! }}} | ||||||||||||||||||||||
Characterize the mass:
Associated symptoms
Detailed history:
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Examine the patient: ❑ Vital signs
❑ Skin
❑ Inspection
❑ Auscultation
❑ Palpation
❑ Psoas sign (suggestive of retrocecal appendix) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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 ❑ Serum electrolytes ❑ ESR ❑ ABG ❑ D dimer ❑ Serum lactate ❑ BUN ❑ Creatinine ❑ Amylase ❑ Lipase ❑ Triglyceride ❑ Total bilirubin ❑ Direct bilirubin ❑ Albumin ❑ AST ❑ ALT ❑ Alkaline phosphatase ❑ GGT ❑ Stool for ova and parasites ❑ C. difficile culture and toxin assay 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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Pulsatile abdominal mass[1][2][3][4] ❑History (such as associated pain, past medical, surgical history) ❑Physical exam (such as location and extent of the mass, change in size) ❑Risk factors for the development of Abdominal AOrtic Aneurysm (AAA) | |||||||||||||||||||||||||||||||||||||||||||||
Assess hemodynamic stability | |||||||||||||||||||||||||||||||||||||||||||||
Unsable | Stable | ||||||||||||||||||||||||||||||||||||||||||||
❑Airway, Breathing and Circulation (ABC) ❑Clinical diagnosis of ruptured AAA considered if patient is/was a smoker, >60 years old, HTN history, an existing diagnosis of AAA, and abdominal/back pain. ❑Immediate bedside aortic US ❑Systolic BP >70 acceptable (permissive hypotension) | |||||||||||||||||||||||||||||||||||||||||||||
Emergency repair (open or endovascular) if expertise are available | Transfer to a facility with vascular specialist expertise | ||||||||||||||||||||||||||||||||||||||||||||
AAA not demonstrated | AAA demonstrated | ||||||||||||||||||||||||||||||||||||||||||||
Look for other possible causes on a CT scan ❑Heart failure (hepatomegaly, portal hypertension, pulmonary edema, and contrast reflux into IVC and hepatic veins) | |||||||||||||||||||||||||||||||||||||||||||||
<5.5cm | ≥5.5cm | ||||||||||||||||||||||||||||||||||||||||||||
No pain demonstrated Rupture risk<operative repair risk (1 year) | No Pain demonstrated Rupture risk>operative repair risk (1 year) Elective repair considered | Pain is present High rupture risk | |||||||||||||||||||||||||||||||||||||||||||
Other causes (low rupture risk) | No other causes (moderate-high risk of rupture) | ||||||||||||||||||||||||||||||||||||||||||||
❑Follow-up in 6M ❑Repair of aneurysm if it grows >0.4cm/year or becomes symptomatic | |||||||||||||||||||||||||||||||||||||||||||||
❑Unruptured AAA (moderate risk)
| ❑Ruptured AAA
| ||||||||||||||||||||||||||||||||||||||||||||
Abdominal US (100% Sn and Sp but visualization among 1-3% patients). [2]
- AAAs are more likely to rupture in women than men.[3]
CT angiography (gold standard for evaluation of AAA).
- ↑ Moussa O, Al Samaraee A, Ray R, Nice C, Bhattacharya V (2010). "A Tender Pulsatile Epigastric Mass is NOT Always an Abdominal Aortic Aneurysm: A Case Report and Review of Literature". J Radiol Case Rep. 4 (10): 26–31. doi:10.3941/jrcr.v4i10.458. PMC 3303349. PMID 22470694.
- ↑ 2.0 2.1 "Abdominal aortic aneurysm | Radiology Reference Article | Radiopaedia.org".
- ↑ 3.0 3.1 "www.nice.org.uk".
- ↑ Starnes, Benjamin (2017). Ruptured abdominal aortic aneurysm : the definitive manual. Cham: Springer. ISBN 9783319238449.