LEFT UPPER QUADRANT MASS

LEFT UPPER QUADRANT MASS: Excerpt from Differential Diagnosis in Primary Care

The differential diagnosis for left upper quadrant (LUQ) masses is not a great deal different from that of the RUQ. The anatomy is similar: just replace the liver with the spleen and the gallbladder with the stomach. The presence of the aorta on the side of the abdomen should not be forgotten. Again, anatomy is the key, as shown in Table 2. Cross-index the various organs and tissues with the etiologies using MINT as the mnemonic.

ABDOMINAL MASS, LUQ

1. M—Malformations of the skin, subcutaneous tissue, fascia, and muscle are usually hernias; for the spleen, they are aneurysms; for the splenic flexure of the colon, they are mainly volvulus, intussusceptions, and diverticula. Gastric dilatation of the stomach is caused by obstruction or pneumonia. Cysts are common for the pancreas, just as polycystic disease, single cysts, and hydronephrosis are common for the kidney. There is no common malformation for the adrenal gland.
2. I—Inflammatory conditions of the skin, subcutaneous tissue, muscle, and fascia are usually abscesses and cellulitis. In the spleen, a host of systemic inflammatory lesions can cause enlargement (see page 482), but primary infections of the spleen are unusual. The colon may be inflamed by diverticulitis, granulomatous colitis, and, occasionally, by tuberculosis. Inflammatory disease of the stomach does not usually produce a mass, but if an ulcer perforates or if a diverticulum ruptures, a subphrenic abscess may form in the left hypochondrium. Inflammatory pseudocysts may form in the tail of the pancreas. A palpable perinephric abscess and an enlarged kidney from acute pyelonephritis or tuberculosis may be felt, but inflammatory lesions of the adrenal gland are rarely palpable.
3. N—Neoplasms of the organs mentioned above account for most of the masses in the LUQ. Carcinoma of the stomach or colon, Hodgkin disease, chronic leukemias involving the spleen, Wilms tumor, carcinoma of the kidney, and neuroblastoma must be considered. A retroperitoneal sarcoma is occasionally responsible for an LUQ mass.
4. T—Trauma to the spleen or kidney will produce a tender mass in the LUQ. Less common traumatic lesions here include contusion of the muscle and perforation of the stomach or colon. It should be noted that the left lobe of the liver may project into the LUQ; therefore, tumor and abscess of the liver must be considered.

Approach to the Diagnosis

The presence or absence of other symptoms and signs is the key to the clinical diagnosis of an LUQ mass. The presence of jaundice would suggest the mass is a large spleen. The presence of blood in the stool would suggest carcinoma of the colon. The presence of hematuria would suggest the mass is renal in origin. An enema should be done to exclude fecal impaction before an extensive workup is performed.

A conservative workup will include a CBC, sedimentation rate, urinalysis, chemistry panel, platelet count, stool for occult blood, coagulation profile, and a flat plate of the abdomen. On the basis of these results, the clinician can determine whether to do an upper gastrointestinal (GI) series, barium enema, IVP, or CT scan of the abdomen. Another approach would be to do the CT scan immediately. In the long run, the latter approach may be more cost-effective. It is usually prudent to get a surgical or gastroenterology consult to help decide between the two approaches.

Other Useful Tests

1. Amylase and lipase levels (pancreatic pseudocyst or tumor)
2. Bone marrow examination (splenomegaly)
3. Liver–spleen scan (splenomegaly)
4. Sonogram (renal cyst, pancreatic cyst)
5. Colonoscopy (colon carcinoma)
6. Laparoscopy
7. Biopsy of mass (neoplasm)
8. Gallium scan (abscess)

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8