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Abdominal Masses: Solid Organs and Gastrointestinal 22 Abdominal Masses: Solid Organs and Gastrointestinal Thomas J. Kearney Objectives 1. To describe the causes of hepatomegaly; to discuss the role of imaging and liver biopsy; to discuss the most frequently encountered benign and malig- nant liver masses and their management. 2. To describe the differential diagnosis of a pancre- atic mass; to discuss the most useful imaging studies and the role of biopsy. 3. To understand the relationship of the pancreatic duct to the common bile duct and how this may affect the diagnosis and treatment of a pancreatic mass; to discuss the management of cysts of the pancreas. 4. To describe the causes of hypersplenism; to discuss the common signs and symptoms of hypersplenism and contrast with splenomegaly; to discuss the role and consequences of splenec- tomy in the treatment of splenic disease. 5. To discuss the most frequently encountered retroperitoneal masses; to contrast the manage- ment of lymphomas and sarcomas. Cases Case 1 A 46-year-old male police officer noticed mild pressure in his abdomen when he bent to tie his shoes. His colleagues teased him that he was getting fat. However, he had not gained any weight. Further question- ing revealed early satiety, and physical examination revealed a large epigastric mass that was firm but not hard. It was not tender. A com- puted tomography (CT) scan was ordered. 409 410 T.J. Kearney Case 2 A 72-year-old woman presented to the hospital with hematemesis. She had noticed a 10-pound weight loss and early satiety over the past month. She denied changes in her bowel habits or jaundice. Physical examination revealed a midline epigastric mass along with an enlarged spleen. Neither was tender. A CT scan was ordered. Case 3 A 22-year-old man complained of bleeding gums and epistaxis. Exam- ination was otherwise unremarkable. He did not have a left upper quadrant mass. Platelet count was 15,000/mL. Case 4 A 48-year-old man presented with increasing abdominal girth and decreased appetite. Examination revealed a large left-sided mass. A CT scan revealed a large mass in the retroperitoneum with fat density. Case 5 A 45-year-old man presented with intermittent nausea and blood in his stools. Examination revealed a mass in the midabdomen. A CT scan suggested a colon cancer that was locally advanced. Colonoscopy revealed a cancer. Introduction Abdominal masses may be caused by a large variety of pathologic con- ditions. All abdominal masses need to be thoroughly and expeditiously evaluated, sometimes with significant urgency. A detailed history and physical examination, combined with knowledge of normal anatomy, allow the physician to generate a reasonable differential diagnosis. Additional diagnostic tests then can be obtained. In certain situations, notably rupturing abdominal aortic aneurysms, the physician must take the patient directly to the operating room without further testing to avoid exsanguination. Several classification systems are available to help guide evaluation of a patient with an abdominal mass (Table 22.1). Surgeons often use Table 22.1. Classification systems for abdomi- nal masses. Anatomic Organ based Location Etiology Clinical course Acute Chronic Urgent 22. Abdominal Masses: Solid Organs and Gastrointestinal 411 Table 22.2. Anatomic classification. Organ based Liver Pancreas Spleen Renal Vascular Gastrointestinal Connective tissue Location based Abdominal wall Intraperitoneal Pelvic Right lower quadrant Left lower quadrant Mid-pelvis Retroperitoneal Flank Epigastric Right upper quadrant Left upper quadrant anatomic systems (Table 22.2). These systems can be divided into an organ-based system or a location-based system. In addition, an etio- logic system (Table 22.3) is equally valuable and may be preferred by some. As always, the physician must be sure the patient does not have an emergency situation requiring immediate operation. General Evaluation A detailed history must include information about the onset of the mass (sudden vs. chronic). Incidentally discovered masses often repre- sent neoplasms. Symptomatic and acute masses imply an infectious or inflammatory cause. Abdominal aneurysm rupture usually is sudden and acute. (See Chapter 23 for vascular abdominal masses.) Changes in size over time and symptoms associated with the gastrointestinal, hepatobiliary, urinary, or gynecologic systems can provide clues to the Table 22.3. Etiologic classification. Neoplastic Benign Malignant Primary Metastatic Infectious Bacterial Parasitic Fungal Traumatic Inflammatory Congenital Degenerative 412 T.J. Kearney nature of the mass. These symptoms could include nausea, vomiting, diarrhea, melena, jaundice, vaginal bleeding, and hematuria. The physician should ask about the presence of pain along with details about pain quality, location, radiation, timing, severity, and factors that alleviate or exacerbate the pain. Details about preexisting or chronic conditions are required. Physical examination should include an evaluation of the patient’s general status, including vital signs and any evidence of impending cardiac or respiratory collapse. Try to identify the general location of the mass. Contour and texture (hard, fluctuant) provide clues to the diagnosis. Evidence of bowel perforation, such as diffuse abdominal tenderness or tympany from free air, should be sought. Examination of the chest as well as rectal and pelvic examination are essential. Masses that are tender and associated with signs of sepsis (fever, hypotension) or masses associated with perforation require urgent evaluation. Upon completion of the history and physical examination, the physician usually knows if urgent evaluation and treatment are needed or if more leisurely evaluation is safe. In nonurgent situa- tions, radiologic evaluation plays a key role. Plain radiographs of the chest and abdomen combined with basic laboratory evaluation (com- plete blood count with differential, electrolytes, renal and liver func- tion, urinalysis, pregnancy test) are the first steps in further evaluation. The plain radiographs should include a flat and upright abdominal film along with posteroanterior and lateral chest radiographs. These films detect signs of perforation or obstruction as well as mass effect. After initial evaluation, the probable site of abnormality guides further workup. Findings suggestive of gastric or colonic disease would lead to endoscopic evaluation or possibly gastrointestinal (GI) contrast studies. If a CT scan is contemplated, it must be performed prior to GI contrast studies. Masses of the uterus and ovaries usually are evaluated initially with ultrasound, either transabdominal or transvaginal. Ultra- sound also is useful for suspected biliary disease as well as for evalua- tion of nonurgent abdominal aortic aneurysms. Masses of the solid organs (liver, spleen, and pancreas) or the retroperitoneum require CT scan, almost always with oral and intravenous contrast. Magnetic reso- nance imaging (MRI) is useful for further characterization of some solid organ masses. Intravenous pyelography (IVP) is useful for evaluation of the urinary system. Cystoscopy is useful for bladder evaluation and should be included in any evaluation of hematuria. Radionuclide imaging is less used than previously due to the excellent anatomic detail available from modern CT scanning. Angiography occasionally is used in the evaluation of operative approaches for abdominal masses. Mag- netic resonance angiography is an evolving technique that may provide similar information less invasively than angiography. Liver Masses Liver masses may present with symptoms or may be discovered inci- dentally on scans done for other reasons. Multiple causes are possible (Table 22.4). Pain usually is dull, aching, and fairly constant. Fever and 22. Abdominal Masses: Solid Organs and Gastrointestinal 413 Table 22.4. Liver masses. Tumors Cysts Abscesses Benign Acquired Pyogenic Hemangioma Parasitic (hydatid) Adenoma Traumatic Focal nodular hyperplasia Malignant: primary Congenital Amebic Hepatoma Single Cholangiocarcinoma Multiple Angiosarcoma Malignant: metastatic Fungal Unresectable Resectable tenderness could represent an infectious etiology, such as abscess. A personal history of cancer, particularly colon and rectal cancer, could be a clue to hepatic metastases. Patients with a history of alcoholism or hepatitis leading to cirrhosis are at risk for hepatocellular cancer. The patient in Case 1 had none of these. His occupation as a police officer may have exposed him to blunt abdominal trauma while arresting a suspect. This could lead to a hematoma, but he could not recall any particular incident. A CT scan revealed a large 12-cm hemangioma of the left lobe of the liver. The patient’s symptoms were managed with mild analgesics, and the decision was made to avoid surgical resection in this patient. On follow-up the next year, size and symptoms had increased. A left hepatectomy was performed. A scheme for manage- ment of liver tumors is presented in Algorithm 22.1. Tumors Tumors of the liver can be classified as benign or malignant. Heman- gioma is the most common benign tumor of the liver, occurring in up to 20% of patients in some autopsy series. They usually are asympto- matic and require removal only if disabling symptoms are present. The risk of rupture is quite low, even in large hemangiomas. The diagnosis can be confirmed with near certainty by an MRI or nuclear imaging studies. Other benign tumors include hepatic adenomas associated with oral contraceptive use in young women. Hepatic adenomas that are symptomatic
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