Diagnosis of Cholecystitis
Diagnostic Test list for Cholecystitis:
The list of medical tests
mentioned in various sources as
used in the diagnosis of Cholecystitis
includes:
Cholecystitis Diagnosis: Book Excerpts
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Abdominal Masses:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Constipation/inability to pass stool
–Most commonly due to dehydration and/or low dietary fiber intake
–Hirschsprung's disease (congenital aganglionic megacolon)
–Medications: Narcotics, opiates, or anticholinergic medications
–Ogilvie's syndrome (colonic pseudo-obstruction)
-
Ascites
–May be due to malignancy, nephrotic syndrome, liver disease, or congestive heart failure
Large or small bowel obstruction Soft tissue mass
–Tumor (e.g., ovarian, uterine, bowel, liver)
–Uterine fibroids
–Lipoma: Soft, fleshy, mobile, and contained in the subcutaneous tissue of the abdominal wall
–Hernia: Bowel sounds may be audible over the mass; incarceration causes pain; strangulation leads to bowel death
–Pyloric stenosis: Seen primarily in infants; palpable pyloric olive-shaped mass
–Pregnancy
–Massive lymphadenopathy (e.g.,
lymphoma)
–Organomegaly (e.g., hepatomegaly, splenomegaly)
–Infection: Intra-abdominal or tubo-ovarian abscess
–Abdominal aortic aneurysm: Associated with pulsatile mass and hypotension
- Cyst
–Mesenteric cysts: Fluid collections in the mesentery; typically benign
–Hydatid cyst: Caused by larval form of Echinococcus granulosus; typically found in the liver in patients with history of travel to tropical areas
–Dermoid cyst: May be massive due to delayed presentation
- Palpable gallbladder (Courvoisier's sign): Associated with common bile duct obstruction and a distended gallbladder
Workup and Diagnosis
- History and physical examination
–Note associated symptoms (especially fever, changes in bowel habits, weight change, urinary symptoms, and rectal bleeding)
–Abdominal and pelvic examinations to localize areas of tenderness
- Initial laboratory studies may include CBC, electrolytes, BUN/creatinine, liver function tests, urinalysis, and β-hCG
-
Tumor markers (if malignancy is a concern), blood cultures (if infection is suspected), and toxicology screen may be indicated
-
Plain KUB X-rays may reveal constipation, obstruction, or free intraperitoneal air
-
Abdominal CT scan with IV and oral contrast will evaluate for abscess, bowel pathology, and hepatosplenomegaly
-
Barium enema may reveal abnormal bowel in cases of malignancy
-
Colonoscopy is useful for diagnosis of bowel pathology
-
Laparoscopy allows direct visualization of the intra-abdominal cavity
-
Paracentesis with fluid evaluation
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Source: In a Page: Signs and Symptoms, 2004
Abdominal Masses:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Wilms tumor
–More common in younger children
-
Neuroblastoma
–More common in younger children
-
Leukemia/lymphoma
–Involvement of retroperitoneal nodes, liver, or spleen
-
Hepatic tumors
–Hepatoblastoma, hepatocellular carcinoma, angiosarcoma, rhabdomyosarcoma of the liver, metastatic disease
-
Germ cell tumors
–Ovarian, teratoma
-
Soft tissue sarcoma
–Rhabdomyosarcoma
-
Rare malignancies in children
–Carcinoid tumors, adrenocortical carcinoma, pancreatoblastoma, malignant rhabdoid tumor
-
Cystic masses
–Ovary, renal, mesenteric
-
Benign tumors
–Adenomas (especially of liver), hamartomas, pheochromocytoma
-
Vascular lesions (e.g., hemangioma)
-
Renal etiologies
–Distended, nonemptying bladder, bladder
outlet obstruction
–Congenital mesoblastic nephroma
–Severe hydronephrosis
-
Gynecologic
–Ovarian torsion, endometriosis, pelvic inflammatory disease
-
Gastrointestinal
–Constipation/stool impaction, intestinal obstruction (e.g., Hirschsprung), GI duplication, incarcerated hernia
-
Pancreatic pseudocyst
-
Infectious
–Abscess, hepatitis, virus (EBV, CMV) causing splenomegaly or hepatomegaly
-
Structures normally palpable in small children are liver edge, spleen tip (especially with viral illness), aorta, sigmoid colon, and spine
Workup and Diagnosis
- History
–Mass duration, growth rate, pain; fever, weight loss, bone pain, night sweats
–Anorexia, vomiting, constipation or diarrhea, early satiety, jaundice; prematurity, umbilical catheterization; opsoclonus, myoclonus (neuroblastoma)
–Vaginal bleeding/amenorrhea, sexual activity, previous pregnancies/fertility, history of STDs; urinary dysfunction, congenital urinary tract anomalies
–Signs of catecholamine excess (sleeplessness,
jitteriness, flushing, hypertension)
-
Family history: Wilms tumor, neurofibromatosis, hepatic tumors, Beckwith-Wiedemann
-
Physical exam: Vital signs, toxicity, pallor, puffiness; location, size, tenderness, consistency of mass; hemihypertrophy (with Wilms), lymph nodes; wheezing, rales, SVC syndrome; presence of ascites, visible venous dilation; testicular exam, rectal; pelvic examination in teenagers; petechiae, purpura/ecchymoses, café au lait spots
-
Labs: CBC with differential; electrolytes, BUN, Cr, LFT albumin, urinalysis; LDH, uric acid, PT/PTT/INR, ferritin, viral titers (EBV, CMV, hepatitis), tumor markers, stool guaiac
-
Studies: KUB/upright film, chest X-ray; CT of chest/abdomen/pelvis; abdominal ultrasound; bone marrow aspirate/biopsy
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Source: In A Page: Pediatric Signs and Symptoms, 2007
ABDOMINAL MASS, GENERALIZED:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
What can be done to work up a diffuse abdominal swelling? It is important to catheterize the bladder if there is any question that this may be the cause. A flat plate of the abdomen and lateral decubiti and upright films will help in diagnosing intestinal obstruction, a ruptured viscus, or peritoneal fluid. A pregnancy test must be done in women of childbearing age. If pregnancy or ovarian cysts can be definitively excluded by ultrasonography, then a computed tomography (CT) scan or diagnostic peritoneal tap may be helpful in the diagnosis.
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Source: Differential Diagnosis in Primary Care, 2007
Abdominal mass:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient’s abdominal mass doesn’t suggest an aortic aneurysm, continue with a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was already aware of the mass. If he was, find out if he noticed any change in the size or location of the mass.
Next, review the patient’s medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in his appetite? If the patient is female, ask whether her menstrual cycles are regular and when the first day of her last menstrual period was.
A complete physical examination should be performed. Next, auscultate for bowel sounds in each quadrant. Listen for bruits or friction rubs, and check for enlarged veins. Lightly palpate and then deeply palpate the abdomen, assessing any painful or suspicious areas last. Note the patient’s position when you locate the mass. Some masses can be detected only with the patient in a supine position; others require a side-lying position.
Estimate the size of the mass in centimeters. Determine its shape. Is it round or sausage shaped? Describe its contour as smooth, rough, sharply defined, nodular, or irregular. Determine the consistency of the mass. Is it doughy, soft, solid, or hard? Also, percuss the mass. A dull sound indicates a fluid-filled mass; a tympanic sound, an air-filled mass.
Next, determine if the mass moves with your hand or in response to respiration. Is the mass free-floating or attached to intra-abdominal structures? To determine whether the mass is located in the abdominal wall or the abdominal cavity, ask the patient to lift his head and shoulders off the examination table, thereby contracting his abdominal muscles. While these muscles are contracted, try to palpate the mass. If you can, the mass is in the abdominal wall; if you can’t, the mass is within the abdominal cavity. (See Abdominal masses: Locations and common causes.)
After the abdominal examination is complete, perform pelvic, genital, and rectal examinations.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Abdominal mass:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient’s abdominal mass doesn’t suggest an aortic aneurysm, take a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was already aware of the mass. If he was, find out if he noticed any change in its size or location.
Next, review the patient’s medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in appetite? If the patient is female, ask whether her menstrual cycles are regular and when the 1st day of her last menstrual period was.
Perform a complete physical examination. Next, auscultate for bowel sounds in each quadrant. Listen for bruits or friction rubs, and check for enlarged veins. Lightly palpate and then deeply palpate the abdomen, assessing any painful or suspicious areas last. Note the patient’s position when you locate the mass. Some masses can be detected only with the patient in a supine position; others require a side-lying position.
Estimate the size of the mass in centimeters. Determine its shape. Is it round or sausage shaped? Describe its contour as smooth, rough, sharply defined, nodular, or irregular. Determine the consistency of the mass. Is it doughy, soft, solid, or hard? Also, percuss the mass. A dull sound indicates a fluid-filled mass; a tympanic sound, an air-filled mass.
Next, determine if the mass moves with your hand or in response to respiration. Is the mass free-floating or attached to intra-abdominal structures? To determine whether the mass is located in the abdominal wall or the abdominal cavity, ask the patient to lift his head and shoulders off the examination table, thereby contracting his abdominal muscles. While these muscles are contracted, try to palpate the mass. If you can, the mass is in the abdominal wall; if you can’t, the mass is within the abdominal cavity. (See Abdominal masses: Locations and causes, page 10.)
After the abdominal examination is complete, perform pelvic, genital, and rectal examinations.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Abdominal/Pelvic Mass:
Differential Overview
(Field Guide to Bedside Diagnosis)
Abdominal Mass
❑ Liver enlargement
❑ Spleen enlargement
❑ Fecal mass
❑ Diverticulitis
❑ Colon cancer
❑ Gallbladder enlargement
❑ Pancreatic pseudocyst
❑ Crohn disease
❑ Abdominal aortic aneurysm
❑ Renal enlargement
Pelvic Mass
❑ Distended bladder
❑ Pregnant uterus
❑ Salpingitis
❑ Ovarian cyst
❑ Uterine fibromyoma
❑ Ovarian cancer
❑ Endometrial cancer
❑ Ectopic pregnancy
❑ Malignant deposit
Diagnostic Approach
Consider the structures in the region of the mass for clues to its origin and the presence of tenderness as an indicator of inflammation/infection. It is possible to miss initially even a relatively large mass unless a systematic four-quadrant examination is performed.
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Source: Field Guide to Bedside Diagnosis, 2007
Cholelithiasis, cholecystitis, and related disorders:
Diagnosis
(Handbook of Diseases)
Ultrasonography and X-rays detect gallstones. Specific procedures include the following:
❑ Ultrasonography reflects stones in the gallbladder with 96% accuracy.
❑ Percutaneous transhepatic cholangiography allows imaging under fluoroscopic control to help distinguish between gallbladder or bile duct disease and cancer of the pancreatic head in patients with jaundice.
❑ Endoscopic retrograde cholangiopancreatography visualizes the biliary tree after insertion of an endoscope down the esophagus into the duodenum, cannulation of the common bile and pancreatic ducts, and injection of contrast medium.
❑ Hepatobiliary iminodiacetic acid analogue scan of the gallbladder helps detect obstruction of the cystic duct.
❑ Computed tomography scan, although not routinely used, helps distinguish between obstructive and nonobstructive jaundice.
❑ Plain abdominal X-rays identify calcified but not cholesterol stones with 15% accuracy.
❑ Oral cholecystography shows stones in the gallbladder and biliary duct obstruction.
Elevated icteric index and elevated total bilirubin, urine bilirubin, and alkaline phosphatase levels support the diagnosis. White blood cell count is slightly elevated during a cholecystitis attack.
Differential diagnosis is essential because gallbladder disease can mimic other diseases (myocardial infarction, angina, pancreatitis, pancreatic head cancer, pneumonia, peptic ulcer, hiatal hernia, esophagitis, and gastritis). Serum amylase levels help distinguish gallbladder disease from pancreatitis. With suspected heart disease, cardiac enzyme testsand an electrocardiogram should precede gallbladder and upper GI diagnostic tests.
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Source: Handbook of Diseases, 2003
Abdominal mass:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient’s abdominal mass doesn’t suggest an aortic aneurysm, continue with a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was aware of the mass. If he was, find out if he noticed any change in the size or location of the mass.
Next, review the patient’s medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in appetite? If the patient is female, ask whether her menstrual cycles are regular and when the first day of her last menses was.
CULTURAL CUE:When taking a health history, consider your patient’s ethnic background. For example, Japanese patients are at higher risk for gastric cancer than non-Japanese patients and cirrhosis tends to be more common in Native American patients than in patients of other ethnic backgrounds.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Abdominal Masses:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Right Upper Quadrant
Liver
Hepatomegaly
Palpablein right upper quadrant of abdomen. Palpable in midline or leftupper quadrant with abdominal heterotaxia (commonly associated withcomplex congenital heart disease).See Chap.30, Hepatomegaly. Hepatic Cyst
May presentas asymptomatic hepatic mass.Abdominal U/S is diagnostic. Primary Hepatic Neoplasms
AbdominalU/S distinguishes between cystic or solid masses. CT defineslocation and extent of tumor.Histologic diagnosis is definitive. Benign
Hemangioma,mesenchymal hamartoma, and focal nodular hyperplasia usually presentin infancy as asymptomatic hepatic masses.Hemangioendothelioma usually presentsbefore 6 mos of age as hepatic mass or with massive hepatomegalyand cardiac failure secondary to multiple arteriovenous communicationswithin tumor. Diagnosis may be confirmed by selective angiography.Hepatic adenoma is rare tumor thatusually presents after puberty.Hepatic teratoma can be benign or malignantand is rare in pediatric age group. Malignant
Hepatoblastomais most common hepatic malignant tumor in pediatric population andusually occurs in children <2 yrs of age.Hepatomegalyis most frequent physical finding. Discrete mass is usually notpalpable.Abdominal U/S shows single,solid liver mass.Serum alpha-fetoprotein (AFP) levelsare increased in most cases. Hepatocellular carcinoma usually occursin children >3 yrs of age, with peak incidence in adolescence.Clinical manifestationsinclude right upper quadrant mass, abdominal pain, anorexia, andweight loss.Abdominal U/S shows solidhepatic mass, and AFP levels may be increased.Often a complication of chronic hepatitisB infection. Gallbladder
Cholecystitis
Occurrenceis usually related to presence of gallstones.Right upper quadrant pain, vomiting,and fever are usual findings. Enlarged tender gallbladder may bepalpable.Abdominal U/S usually revealsstones and thickened gallbladder wall. Hydrops of Gallbladder
Hydropsrefers to distension of gallbladder without inflammation.Causes include Kawasaki disease, nephroticsyndrome, staphylococcal or streptococcal infection, and, in neonates,septicemia and total parenteral nutrition.Gallbladder is enlarged and often palpable.Abdominal U/S confirms thatmass is gallbladder. Biliary Tree
Choledochal Cyst
Infantsmay present with jaundice, acholic stools, and hepatomegaly. Childrenmay present with jaundice, abdominal mass, or abdominal pain.4 types are fusiform dilation of commonbile duct (most common), diverticulum of common duct, dilatationof distal portion of common duct, and dilatation of extra- and intrahepaticbile ducts.Diagnosis usually confirmed by abdominalU/S. Intestine
Pyloric Stenosis
Hypertrophicpyloric stenosis produces an olive-sized mass in right upper quadrant ofabdomen, but it is not always palpable.Usually occurs in infants 1–8wks of age.Most consistent finding is persistentnonbilious vomiting during or immediately after feeding.Physical exam can be diagnostic ifmass is palpable.Diagnosis can be confirmed by abdominalU/S or upper GI radiographic series. Duodenal Hematoma
Usuallycaused by blunt abdominal trauma.Common findings are abdominal painand bilious vomiting. Mass may be palpable in right upper quadrantor epigastric region.Abdominal U/S or upper GIradiographic series is diagnostic. Duplication
Can occuranywhere in GI tract but most commonly involves ileum and colon.Compressible mass may be palpable anywhere in abdomen. Abdominalpain, vomiting, and GI bleeding are common findings.Abdominal U/S and CT are usuallydiagnostic. Technetium 99m–pertechnetate scan can detectectopic gastric mucosa.Diagnosis is confirmed at surgery. Left Upper Quadrant
Spleen
Splenomegaly
Enlargedspleen is normally palpable in left upper quadrant of abdomen, unlessabdominal heterotaxia exists, in which case it is palpable in midlineor right upper quadrant.Abdominal heterotaxia is usually associatedwith congenital complex heart disease.See Chap.62, Splenomegaly. Splenic Cyst
May be congenitalor occur secondary to trauma.Smooth mass that displaces stomachmedially is usually palpable.Abdominal U/S is diagnostic. Neoplasm
See Chap.62, Splenomegaly.
Epigastric
Stomach
Bezoar
May be palpableas epigastric mass. Vomiting and abdominal distension are common findings.Abdominal U/S or upper GIseries is diagnostic.See Chap.55, Regurgitation and Vomiting. Duplication
Frequentmanifestations are vomiting and epigastric mass. Bleeding from duplication alsomay produce hematochezia.Abdominal U/S is usually diagnostic. Pancreas
Pancreatic Cyst
May presentas asymptomatic abdominal mass or with abdominal distension, vomiting,and jaundice.Abdominal U/S or CT is usuallydiagnostic. Pancreatic Pseudocyst
Accountsfor majority of cystic lesions of pancreas and is usually locatedin lesser sac.Its wall is composed of granulationtissue and not epithelium.Most common causes are abdominal traumaand pancreatitis (idiopathic).Abdominal pain, vomiting, anorexia,weight loss, and epigastric mass are frequent findings.Combination of abdominal U/Sand CT is usually diagnostic. Neoplasm
Usuallycarcinomas or rare endocrine tumors.Abdominal U/S and CT locateand define extent of mass. Histologic diagnosis is definitive. Right/Left Mid-Abdomen
Kidney
In neonates, >50% of abdominalmasses involve urinary tract. Most are unilateral.
Hydronephrosis
Definedas distension of kidney pelvis and calyces produced by obstructionanywhere in genitourinary tract.Most common abdominal mass in neonate;can be unilateral or bilateral.Specific causes include ureteropelvicjunction, ureteral, or ureterovesical obstruction; ureterocele;posterior urethral valves; and prune belly syndrome. Besides largeabdominal or flank mass, abdominal or flank pain, hematuria, vomiting,poor weight gain, recurrent fever, and urinary tract infection mayoccur.Abdominal U/S is usually diagnostic.Useful tests to determine site of obstructioninclude excretory urography, voiding cystourethrography, cystoscopy,and retrograde pyelography. Multicystic Dysplastic Kidney
Second mostcommon abdominal mass found in neonate.Usually unilateral and asymptomatic.Consists of cysts of various sizesand is almost always nonfunctional.Although abdominal U/S isdiagnostic, renal scintigraphy is useful in demonstrating renal function. Renal Vein Thrombosis
Occurs mostcommonly in neonatal period and can be unilateral or bilateral.History of perinatal asphyxia or hypovolemiausually exists. Maternal diabetes mellitus is frequent association.Common findings include flank mass,hematuria, proteinuria, azotemia, thrombocytopenia, and transienthypertension.Abdominal U/S or CT is usuallydiagnostic.Renal scintigraphy demonstrates kidneyfunction, which may be diminished in 1 or both kidneys. Congenital Mesoblastic Nephroma
Usuallypresents as asymptomatic abdominal or flank mass.Renal U/S locates solid tumor.Histologic diagnosis is confirmatory. Wilms Tumor
Definedas embryonal renal tumor that usually presents as unilateral, smooth,mobile flank mass before 3 yrs of age. May be bilateral. Abdominalpain, hematuria, fever, hypertension, aniridia, and hemihypertrophymay occur.Combination of abdominal U/Sand CT define location and extent of tumor, including any presencein inferior vena cava. Histologic diagnosis is definitive. Renal Cyst, Ectopic Kidney, and Horseshoe Kidney
May presentas abdominal or flank masses.Abdominal U/S confirms diagnosis. Renal or Perinephric Abscess
High spikingfever and abdominal or flank mass suggest renal or perinephric abscess.Abdominal U/S and CT are usuallydiagnostic. Percutaneous needle drainage or surgery confirms diagnosis. Polycystic Kidney Disease
Autosomal-recessivepolycystic kidney disease can present in neonatal period with bilateralflank masses, which are firm, large, irregular kidneys. Other findingsinclude hematuria, proteinuria, azotemia, and hypertension.Abdominal U/S reveals largeechogenic kidneys.Autosomal-dominant polycystic kidneydisease, which usually occurs in adults, also can present with unilateralor bilateral enlarged kidneys. Beckwith-Wiedemann Syndrome
Autosomal-dominantdisorder that can occur sporadically.Kidneys may be enlarged. Other manifestationsinclude generalized overgrowth, macroglossia, omphalocele, and hepatomegaly.Hypoglycemia is most urgent featurein newborn.Gene locus has been mapped to chromosome11p15.5. Adrenal
Neonatal Adrenal Hematoma
May occurafter traumatic delivery, asphyxia, or septicemia.With massive bleeding, infant may presentin shock. With less severe bleeding, abdominal mass may be palpable,usually on right side and accompanied by anemia and jaundice. Massusually decreases in size and disappears over several weeks.Abdominal U/S is usually diagnostic. Neuroblastoma
May arisefrom adrenal medulla or any site along sympathetic chain.Mean age of presentation is about 2yrs of age.Hard, fixed abdominal mass is commonfinding. Abdominal pain, weight loss, fever, bone pain, eyelid ecchymoses,and bluish subcutaneous nodules also may occur. In some cases opsoclonusand cerebellar ataxia have been noted.Metastases may involve regional lymphnodes, bone marrow, bone, liver, and skin.Abdominal radiographs may show massand typical punctate calcifications. Abdominal U/S alsocan locate mass, while CT or MRI can define its extent.Increase in 24-hr urine excretion ofcatecholamines (norepinephrine, dopamine, normetanephrine, homovanillicacid, vanillylmandelic acid) is usually found.Chest radiograph, skeletal bone survey,nuclear scintigraphy, and bone marrow aspirate should be performedsearching for metastatic disease.Diagnosis confirmed by histologic examof tissue. Periumbilical
Intestine
Mesenteric Cyst
Usuallyarises in mesentery of jejunum or ileum and enlarges slowly.Abdominal mass is often palpable.Abdominal U/S is usually diagnostic. Volvulus
Infantspresent with symptoms and signs of intestinal obstruction such aspersistent vomiting and abdominal distension. Occasionally abdominalmass may be palpable.See Chap.22, Gastrointestinal Bleeding and Chap. 55, Regurgitation and Vomiting. Neoplasm
Tumors ofGI tract in newborn and young infant are extremely rare.In their series, Longino and Martin(1958) described just 1 case of leiomyosarcoma of colon.In children and adolescents, most commontumor of GI tract is non-Hodgkin lymphoma. Right Lower Quadrant
Intestine
Abscess
May producemass in right lower quadrant.Usual findings are high, spiking, persistentfever and localized abdominal pain and tenderness. Tender mass maybe palpable on rectal exam.Many are due to ruptured appendix.CT is usually diagnostic. Diagnosisof appendiceal abscess is confirmed at interval appendectomy, whichusually occurs about 6 wks after drainage of abscess. Intussusception
Usuallyoccurs at 6–24 mos of age.Other findings that suggest diagnosisare intermittent, colicky abdominal pain; vomiting; and currantjelly, blood-tinged, or guaiac-positive stools.If suspected clinically, perform aircontrast enema, which may be therapeutic as well as diagnostic. Lymphoma
May presentas abdominal mass ± intestinal obstruction.Localized or generalized lymphadenopathymay provide clue to diagnosis, and lymph node biopsy may be diagnostic.Abdominal U/S and CT usuallylocate and define extent of mass.Histologic diagnosis is definitive. Ovary
Cyst
May be asymptomaticand only found on routine exam. May also present with acute abdominalpain secondary to torsion or hemorrhage or with chronic abdominalpain.Most occurrences in adolescence aresimple follicular cysts that persist because of failure of maturingfollicle to ovulate and involute. Resolution usually occurs in 1–2mos.Abdominal U/S is diagnostic. Torsion
Producesacute abdominal pain, which may be accompanied by nausea, vomiting,and fever.Abdominal U/S is often diagnostic.Diagnosis confirmed at surgery. Neoplasm
Rare inpediatric population.Teratoma is most common benign tumor,whereas malignant tumors include dysgerminoma, endodermal sinustumor, immature teratoma, mixed germ cell tumor, embryonal carcinoma,and choriocarcinoma.Palpable abdominal mass and varyingdegrees of acute or chronic abdominal pain may occur.Less common findings are constipation,urinary incontinence, precocious puberty, vaginal bleeding, andamenorrhea.Abdominal U/S localizes mass,determines whether it is cystic or solid, and detects any calcifications.Tumor markers (e.g., AFP, hCG, lacticdehydrogenase, carcinoembryonic antigen) may be useful for selectedtumors.Abdominal CT and MRI help define siteand extent of tumor and if there are any local metastases. Histologicdiagnosis is definitive. Left Lower Quadrant
Intestine
Constipation
Most commoncause of abdominal mass or masses in infancy and childhood.History usually exists of strainingwhile attempting to have bowel movement. Stools are hard and difficultto pass. Multiple, mobile stool masses usually occur in left lowerquadrant and disappear with defecation.Sometimes rectal exam reveals a fecalimpaction.See Chap.9, Constipation. Hypogastrium
Bladder
Distension/Obstruction
Can usuallybe recognized on abdominal exam, or if necessary, by abdominal U/S.Common causes are urethritis, anticholinergicdrugs, and lower urinary tract obstruction from lesions such asposterior urethral valves (males). Uterus
Pregnancy
Intrauterinepregnancy presents as midline lower abdominal or pelvic mass insexually active female.Symptoms and signs of early pregnancyinclude missed menstrual period, nausea, vomiting, lack of usualenergy, and enlarged tender breasts.After 12 wks' gestation, uterinefundus may be palpable above symphysis pubis.After 20 wks' gestation, uteruscan reach level of umbilicus.Positive urine hCG pregnancy test confirmsdiagnosis. Hydrometrocolpos
Definedas fluid-filled dilated vagina and uterus that may be due to imperforatehymen or vaginal atresia.Imperforate hymen can be noted on genitalexam. With vaginal atresia, dimpled area occurs where vaginal openingshould be.Delay of diagnosis until adolescenceresults in failure of menstrual flow and enlarged palpable uterus.Abdominal or pelvic U/S isuseful in diagnosis. Diagnostic Approach
Age of child,location and characteristics of mass, and associated clinical findingsare important factors in diagnosis.Liver masses are in right upper quadrant,splenic masses in left upper quadrant, and kidney masses in flanks;masses involving intestine and ovaries are likely to be palpablein lower quadrants.Any solid mass should be consideredmalignant until proved otherwise.If diagnosis is uncertain after historyand physical exam, abdominal radiographs should be performed.Most useful single test is abdominalU/S, which usually locates involved organ of origin and whethermass is solid or cystic, renal or extrarenal.CT and MRI play important role by demonstratinganatomic features of mass as well as local and metastatic extentof malignant lesions.Chest radiograph may be useful, especiallywith suspected neoplastic lesions. Renal Masses
Responsiblefor >50% of palpable abdominal masses in neonates.If mass is intrarenal, cystic, andsolitary, it is usually benign renal cyst. If it is cystic and multiloculated,renal multicystic dysplasia is usual diagnosis.In infants <1 yr, solid renalmasses are either congenital mesoblastic nephroma or Wilms tumor.These 2 tumors are indistinguishable by imaging exam.In children >1 yr, nearlyall solid intrarenal masses are Wilms tumors. Gastrointestinal Masses
Plain abdominalradiography and abdominal U/S are most important initialstudies.Other studies depend on suspected diagnosis:air-contrast enema (intussusception), CT (intestinal duplication,abscess, neoplasm), and upper GI series (volvulus). Liver Masses
Cystic lesionsare usually benign cysts, whereas solid intrahepatic lesions usuallysignify tumor. In latter case, CT and/or MRI help definelocation and extent of the mass.Histologic diagnosis is confirmatory. Splenic Masses
May be diagnosedby abdominal U/S.Malignant disease usually is infiltrativein nature (leukemia) and causes splenomegaly rather than discretesplenic mass. Involvement of the spleen by lymphoma may be infiltrativeor with discrete tumor foci. Biliary Tract Masses
Most arecystic and benign (choledochal cyst, hydrops of gallbladder) inchildren.Can usually be diagnosed by abdominalU/S. Adrenal Masses
Abdominal U/S can distinguish adrenalhematoma from neuroblastoma. Imaging cannot distinguish betweenneuroblastoma, ganglioneuroma, or ganglioneuroblastoma, and histologicdiagnosis is mandatory.
Genital Tract Masses
Usuallyovarian cysts in infant girls.May be readily diagnosed by abdominalU/S.Most common pelvic tumors in girlsare ovarian tumors. Further imaging is needed with CT or MRI.With pelvic mass in postmenstrual female,pregnancy test and U/S should be performed.If mass appears to be small functionalfollicular cyst, individual should be observed for 2–3mos to see whether it regresses.If it is >5 cm in diameterat time of diagnosis or suspicion of malignancy exists, laparoscopy orlaparotomy should be performed to make definitive histologic diagnosis. Pancreatic Masses
Most arepseudocysts and require no further imaging other than abdominalU/S.Rarely, solid pancreatic tumors occurand are either carcinomas or endocrine tumors. >>
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Abdominal mass:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient's abdominal mass doesn't suggest an aortic aneurysm, continue with a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was already aware of the mass. If he was, find out if he noticed any change in the size or location of the mass.
Next, review the patient's medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in his appetite? If the patient is female, ask whether her menstrual cycles are regular and the first day of her last menses.
A complete physical examination should be performed. Inspect the abdomen for asymmetry, scarring, discoloration, or other skin abnormalities. Also observe for pulsations. Next, auscultate for bowel sounds in each quadrant. Listen for bruits or friction rubs, and check for enlarged veins. Lightly palpate and then deeply palpate the abdomen, assessing any painful or suspicious areas last. Note the patient's position when you locate the mass. Some masses can be detected only with the patient in a supine position; others require a side-lying position.
Estimate the size of the mass in centimeters. Determine its shape. Is it round or sausage shaped? Describe its contour as smooth, rough, sharply defined, nodular, or irregular. Determine the consistency of the mass. Is it doughy, soft, solid, or hard? Percuss the mass. A dull sound indicates a fluid-filled mass; a tympanic sound, an air-filled mass.
Next, determine if the mass moves with your hand or in response to respiration. Is the mass free-floating or attached to intra-abdominal structures? To determine whether the mass is located in the abdominal wall or the abdominal cavity, ask the patient to lift his head and shoulders off the examination table, thereby contracting his abdominal muscles. While these muscles are contracted, try to palpate the mass. If you can, the mass is in the abdominal wall; if you can't, the mass is within the abdominal cavity. (See Abdominal masses: Locations and common causes, page 8.)
After the abdominal examination is complete, perform pelvic, genital, and rectal examinations.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Abdominal Mass, Generalized:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
What can be done to work up a diffuse abdominal swelling? It is
important to catheterize the bladder if there is any question that this may
be the cause. A flat plate of the abdomen and lateral decubiti and upright
films will help in diagnosing intestinal obstruction, a ruptured viscus, or
peritoneal fluid. A pregnancy test must be done in women of childbearing
age. If pregnancy or ovarian cysts can be definitively excluded by
ultrasonography, then a computed tomography (CT) scan or diagnostic
peritoneal tap may be helpful in the diagnosis.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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