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Abdominal Masses

Although vomiting, abdominal pain, GI bleeding,hematuria, and fever accompany some types of abdominal mass lesions,other types occur without any associated signs and symptoms. Thus,it is especially important to examine the abdomen on each medicalvisit.

Principal Causes of Abdominal Masses

  1. Rightupper quadrant
    1. Liver
      1. Hepatomegaly
      2. Hepatic cyst
      3. Primary hepatic neoplasms
    2. Gallbladder
      1. Cholecystitis
      2. Hydrops of the gallbladder
    3. Biliary tree
      1. Choledochal cyst
    4. Intestine
      1. Pyloric stenosis
      2. Duodenal hematoma
      3. Duplication
  2. Left upper quadrant
    1. Spleen
      1. Splenomegaly
      2. Splenic cyst
      3. Neoplasm
  3. Epigastric
    1. Stomach
      1. Bezoar
      2. Duplication
    2. Pancreas
      1. Pancreatic cyst
      2. Pancreatic pseudocyst
      3. Neoplasm
  4. Right/left mid-abdomen
    1. Kidney
      1. Unilateral
        1. Hydronephrosis
        2. Multicystic dysplastic kidney
        3. Renal vein thrombosis
        4. Congenital mesoblastic nephroma
        5. Wilms tumor
        6. Renal cyst
        7. Ectopic kidney
        8. Horseshoe kidney
        9. Renal or perinephric abscess
      2. Bilateral
        1. Hydronephrosis
        2. Multicystic dysplastic kidney
        3. Renal vein thrombosis
        4. Polycystic kidney disease
        5. Beckwith-Wiedemann syndrome
    2. Adrenal
      1. Neonatal adrenal hematoma
      2. Neuroblastoma
  5. Periumbilical
    1. Intestine
      1. Mesenteric cyst
      2. Volvulus
      3. Duplication
      4. Neoplasm
  6. Right lower quadrant
    1. Intestine
      1. Abscess
      2. Intussusception
      3. Lymphoma
    2. Ovary
      1. Cyst
      2. Torsion
      3. Neoplasm
  7. Left lower quadrant
    1. Intestine
      1. Constipation
    2. Ovary (see right lower quadrant)
  8. Hypogastrium
    1. Bladder
      1. Distension/obstruction
    2. Uterus
      1. Pregnancy
      2. Hydrometrocolpos

Clinical Features and Diagnosis

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.

    • References

    1. Altschuler SM, Liacouras CA, eds. Clinicalpediatric gastroenterology. Philadelphia: Churchill Livingstone,1998.
    2. Auringer ST, et al. Congenital cyst of the pancreas.J Pediatr Surg 1993;28:1570–1571.
    3. Avery GB, et al., eds. Neonatology: pathophysiologyand management of the newborn, 5th ed. Philadelphia: LippincottWilliams & Wilkins, 1999.
    4. Emans SJH, et al. Pediatric and adolescent gynecology,4th ed. Philadelphia: Lippincott-Raven, 1998.
    5. Kirks DR, ed. Practical pediatric imaging: diagnosticradiology of infants and children, 3rd ed. Philadelphia: Lippincott-Raven,1998.
    6. Kirks DR, et al. Diagnostic imaging of pediatric abdominalmasses: an overview. Radiol Clin North Am 1981;19:527–545.
    7. Longino LA, Martin LW. Abdominal masses in the newborninfant. Pediatrics 1958;21:596–604.
    8. Online Mendelian Inheritance in Man (OMIM). McKusick-NathansInstitute for Genetic Medicine, Johns Hopkins University (Baltimore,MD) and National Center for Biotechnology Information, NationalLibrary of Medicine (Bethesda, MD), 2000. World Wide Web. URL: http://www.ncbi.nlm.nih.gov/omim.
    9. Pizzo PA, Poplack DG, eds. Principles and practiceof pediatric oncology, 3rd ed. Philadelphia: Lippincott-Raven, 1997.
    10. Rowe MI, et al. Essentials of pediatric surgery. St.Louis: CV Mosby, 1995.
    11. Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.
    12. Suchy FJ, et al., eds. Liver disease in children, 2nded. Philadelphia: Lippincott Williams & Wilkins, 2001.
    '>>

    Book Source Details

    • Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
    • Author(s): Paul S. Bellet
    • Year of Publication: 2006
    • Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

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    Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.

    More About Causes of Stomach ache



    More About This Book:
    Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
    Authors: Paul S. Bellet
    Publisher: Lippincott Williams & Wilkins
    Copyright: 2006
    ISBN: 0-78172-899-1

     » Next page: Abdominal distention (Nursing: Interpreting Signs and Symptoms)

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