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Approach to abdominal mass in pediatrics ..

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esraa y

on 13 January 2014

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Transcript of Approach to abdominal mass in pediatrics ..

The differential diagnosis of an abdominal mass in children depends on
age , the cystic or solid nature of the mass, and the presence of associated symptoms
.
In newborns
, most lesions are
cystic
, although
neuroblastoma
and
teratoma
occur with some frequency.

In older children,
most lesions are
solid
, with
neuroblastoma
and
Wilms tumor
being the most common. It is necessary to refer children with solid tumors to a pediatric oncology center early in the evaluation to facilitate diagnostic studies and to ensure a multidisciplinary approach to treatment.
- Look for a history of
cramping, abdominal pain and vomiting.
Positive findings for these symptoms can point you to pathologies of the gastrointestinal tract such as
intussusception of volvulus.

Objectives
- History ..
- Examinations ..
- Investigations ..
- DDX
- management ..
- complications ..
Approach to
abdominal mass
in pediatrics ..

Past Hx :
Medical hx:
associated medical illnesses
Esra'a Al-Moghamsi ..
Rahaf Al-Ofi ..
Fatimah Al-Hussaini ..
History
Examinations
Investigations
Differential Diagnosis
Management
Complications
An abdominal mass in a neonate,
young child, or adolescent patient is something
that every pediatrician needs to be wary of
as these masses can indicate malignancy.
An organized approach to abdominal masses includes
thinking about possible etiologies based on the location
of the mass with regards to the underlining abdominal
anatomy as well as likely pathologies based on the
age of the patient and associated
symptoms or signs.

Put in mind..
It can present as
...

an asymptomatic abdominal mass
!!
•What are the points of the history do you want to know ?

Personal Hx:
· - The age of the patient :
it can differentiate between likely aetiologies
(children vs neonates).
In general,
older children are more at risk of developing
malignant masses compared to neonatesand young children.

Of the malignant conditions,
children younger than 2 are more likely to suffer from
neuroblastoma
and
hepatoblastoma
, where as older children are more susceptible to
Wilms tumour, hepatocellular carcinoma, genitourinary tract tumours,
and
germ line tumours.
Present Hx:
The mass
Site, onset, duration, progression, associated pain, changes
in eating , aggravating and reliving factors, history of trauma

- Ask the patient
where
the mass was observed.
Think of hepatoblastoma, Wilm's tumor of the right kidney, neuroblastoma of the right adrenal gland, or enlarged gall bladder if mass was found in the upper right quadrantز
- Length of time
since the mass was found.
Masses that have been around for a long time (several months to years) are more likely to be benign.
- The rate of growth of the abdominal mass.

Masses that grow faster are more
likely to be malignant
· - You should ask for presence of constitutional symptoms
pallor, anorexia, weight loss, and fever.

Ask about
constipation, oliguria
..
that might indicate gastrointestinal
or genitourinary obstruction.

· Ask about the presence or absence of
watery diarrhea
.
A positive finding here can indicate a
vasoactive intestinal peptide secreting neuroblastoma
- presence of
hematuria
.
A positive finding here can clue you in to a pathology that results
in damage to the genitourinary tract such as
Wilms tumor
.
Birth hx:
prematurity, difficult birth
Ask about pre-natal interventions as well as review prenatal ultrasounds (US). The US can show the presence of
oligohydramnios or polyhydraminis
(excess amniotic fluid) which may suggest a
congenital renal etiology for the abdominal mass
Don't forget !!
Examine the child in his mother's lap

Warm your hands prior to examination

General Ex:

- A complete general physical exam with vitals .
A
fever
may indicate an infection.
Hepatitis,mononucleosis, or leptospirosis
are three infections
that can cause abdominal masses derived from the liver,
the spleen, and the gallbladder respectively.

- Measure height and weight and plot it on a growth chart.
- Examine the eye and the area around the eye.
Bruising around the eye (
periorbital ecchymosis
) and bulging eyeballs (
proptosis
) may indicate
metastatic neuroblastoma
.
- Patients that lack an iris (
aniridia
) with abdominal masses most likely have a
Wilms tumor
.
Local Ex:
- Inspection:

Done with the patient supine. Look for evidence of
protrusion
,
bulging
, or
asymmetry on the abdomen
.
- Auscultation:
Listen for bowel sounds to assess for
intestinal obstruction
- Palpation:

light palpation of 4 quadrants and flank area. Followed by deeper palpation of the all quadrants.
palpate mass for tenderness, and texture. Look for guarding and organomegaly.
·
- Percussion:
Useful for determining organ size, such as the liver.
And if the mass is a fluid filled cyst with dull percussion or an air-filled structure which will sound tympanic upon percussion.
other systems ..
Chest: respiratory problems.

CVS: congestive heart failure
GU: ambiguous genitalia, hypospadias.
Lymphadenopathy

Laboratory Evaluation
1- Complete blood count with differential can be performed.
Anemia
,
neutropenia
, or
thrombocytopenia
can indicate
bone marrow infiltration
.

2- Bone marrow biopsy and/or aspiration is indicated if one or more bone marrow cell lines are compromised

3- Chemistry panel, including electrolytes, uric acid, and LDH levels.
An
elevated uric acid or LDH
can suggest that a
malignancy
may be present.
Electrolyte abnormality
indicates pathology with the
kidney
or
tumor lysis syndrome
.
4-
Urine analysis:
hematuria or proteinuria suggest renal involvement

5- Serum
B chorionic gonadotropin
and
alfa-feto protein
can be used to find
teratomas, liver, and germ cell tumor
Imaging
• Plain abdominal radiographs:
o Rule out intestinal obstruction, identify calcifications, fecal impaction.

Abdominal ultrasound:
o Can usually identify the origin of the mass and differentiate between solid and cystic tissue; disadvantages are operator variability and a limited exam when bowel gas obscures underlying abdominal tissues.

CT scan:
o Can provide more detail when there is overlying gas or bone; if malignancy is suspected should do chest, abdomen, and pelvis CT
• Magnetic resonance imaging:
o Vascular lesions of liver, major vessels, and tumors
• Radioisotope cholescintigraphy (HIDA) scan:
o Liver, gallbladder

Voiding cystourethrography or intravenous urography:
o Wilms tumor, cystic kidney disease, posterior urethral
valves, hydronephrosis


Upper GI study and barium enema:
o May be of benefit when the mass involves the intestine


A 2 year old healthy male presents to his pediatrician for his routine well-child visit. On examination, the
child was noted to have increased abdominal girth, and a large upper abdominal mass was palpated. The
mass appeared non-tender, firm, and non-mobile. He is asymptomatic.


1. Given the age of the patient and the characteristics of the mass, the differential diagnosis for
malignant tumors includes which of the following:


A. Neuroblastoma, Wilms’ tumor, Hepatoblastoma
B. Non-Hodgkin Lymphoma, Germ cell tumor, Wilms’ tumor
C. Hepatocellular carcinoma, Wilms’ tumor, Neuroblastoma
D. Neuroblastoma, Non-Hodgkin’s Lymphoma, Renal cell carcinoma

2. Initial radiographic evaluation of an
abdominal mass may include all of the following EXCEPT:


A. MRI/CT scan
B. PET/CT scan
C. Abdominal Ultrasound
D. Plain X-ray of the abdomen
Let’s Manage This Mess ;P

MASS

Solid
Vs
cystic
Management of
Solid Tumors
- After careful diagnostic evaluation, patients with solid tumors need either a
diagnostic biopsy
or
tumor resection
.

- The method of confirming the diagnosis and the decision whether to attempt resection depend on the
type of tumor
and the
presence of distant or local spread.

This decision is usually made in consultation with a
pediatric oncologist, a pediatric surgeon, and a radiotherapist.

Malignant tumors usually require additional
chemotherapy
or
radiotherapy
. If dissemination is widespread or if complete resection cannot be performed, chemotherapy may be warranted before resection is attempted.
Management of
Cystic Lesions
Cystic lesions may require
operative therapy
,
medical management
, or
observation
.

Adrenal hemorrhage
 is a neonatal condition that resolves
spontaneously
, although it must be distinguished from a 
cystic neuroblastoma
 by measuring urinary catecholamines. Serial ultrasound examinations are used to monitor its resolution. 


-
Ovarian cysts
 are common in newborns, resulting from stimulation from maternal hormones. Recent studies using prenatal ultrasonography have shown that many of these cysts resolve
spontaneously
, particularly if they are 3 cm or less in diameter.

Ovarian cysts
with torsion
 require
operative therapy
in an attempt to preserve the ovaries and the fallopian tube.


Obstructive uropathy
 requires further investigation, including voiding cystourography, renal nuclear scan, and possible cystoscopy.
Chronic suppressive antibiotic therapy
is used in children with severe
vesicoureteral reflux
 and partially obstructing uropathy.
Cysts of the mesentery
,
bowel wall
, or 
extrahepatic biliary tree
 require
excision
with reconstruction.
Hydrometrocolpos
, which presents in the neonatal period or at the onset of menses, warrants
excision
of the imperforate hymen or, in cases of distal vaginal atresia, vaginal reconstruction.
General Measures..
- Immediate hospitalization
for patients who present with an abdominal mass and signs and/or symptoms of intestinal obstruction
- Initial diagnostic studies
should include an abdominal ultrasound and a surgical or oncological consultation as indicated.
- The remaining causes of abdominal masses require urgent care and timely evaluation and referral to appropriate specialists.

Surgery ..!!
Surgical consultation is often necessary in
the early stages of evaluation and management of an abdominal mass
, emergently if there is concern for intestinal or biliary obstruction.
- Peri-operative
Ileus is common after any abdominal surgery
Post-op intussusception is well reported

- Long Term
Is dependent on the tumor type and whether rupture has occurred
Potential for adhesive bowel obstruction

Post-operative Management
- In most situations, the pathology results will be ready prior to the discharge of the patient

- Discussion with the oncology team to determine whether chemotherapy and/or radiotherapy is needed and if prior to discharge
Clinical Pearls
• - In neonates, a palpable liver edge can be normal; the total liver span is most important.
• - In infants, a full bladder is often mistaken for an abdominal mass.
• - In infants, most abdominal masses are of renal origin and nonmalignant.
• - Severe constipation in older children and adolescents can present as a large, hard mass extending from the pubis past the umbilicus.
• - Gastric distention should be considered in all children who present with a tympanitic epigastric mass.
Operation
Each type of mass has its own approach
In general terms, knowing the goals of surgery is important:

Staging, obtain tissue for diagnosis, resection, assistance with radiotherapy, or assistance with chemotherapy.
Staging
Staging may merely involve assessment of the mass and closing if spread to entire peritoneum.

However, usually need to consider whether the mass has grown into surrounding structures.
And sampling lymph nodes to assess for locoregional spread.

Diagnostic
- If the mass is large and/or involving other structures such that a complete resection is not possible, then a portion of the tumor should be sampled to provide tissue for diagnosis.
- At least 1 cubic cm of tissue
is needed.
- Send fresh (i.e. no formalin)
Resection
-In most situations, an attempt at resection will be the case.
-Preoperative imaging needs to be studied carefully with interest in the vascular supply.
-Care to avoid disruptionof the margins to avoid tumor rupture.
Radiotherapy
- Some tumors may benefit from post-operative radiotherapy
-To assist this, placing surgical clips at the margins of resection will be helpful
-And documentation of the location of the tumor in the operative notes will also help the radiation oncologist
Chemotherapy
- In those chemoresponsive tumors, placement of a central venous catheter under the same anesthetic as the mass resection will avoid a second anesthetic
- The type of central line should be discussed with the oncology staff
Admission Criteria
Immediate hospitalization for patients who present with an abdominal mass and signs and/or symptoms of intestinal obstruction (intussusception, volvulus, gastric torsion, bezoar, foreign body):

- Toxic megacolon
- Ovarian torsion
- Ectopic pregnancy
- Biliary obstruction (stone, hydrops)
- Fever
- Pancreatitis (pseudocyst)
Issues For Referral
Except for the diagnosis of constipation, the presence of an abdominal mass requires immediate attention, and diagnostic studies should be performed expeditiously at a facility capable of diagnosing pediatric disorders.

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