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Abdominal Mass/Hepatosplenomegaly 1 D a V I D T a T E Cambridge University Press 978-1-107-63357-5 - Acute Medicine: A Symptom-Based Approach Edited by Stephen Haydock, Duncan Whitehead and Zoë Fritz Excerpt More information Chapter Abdominal mass/hepatosplenomegaly 1 D a v i d T a t e Introduction Systemic enquiry ( ‘red fl ags’ for malignancy ) Th e identifi cation of an abdominal mass can be a • Fever and night sweats stressful time for the patient. It is imperative to care- • Weight loss (unintentional ≥ 3 kg) fully formulate a diff erential diagnosis based upon the • Dysphagia abdominal fi ndings and the clinical context: patients • Change in bowel habit rarely present with just an abdominal mass . A prompt • Blood per rectum diagnosis may enable the patient to quickly be reas- • Visible haematuria sured of a benign cause or rapidly provided with access • Intermenstrual bleeding to appropriate specialist care and treatment. • Anorexia No table can be entirely inclusive on this topic; we Family history are confi dent you could recall additional causes under • Malignancy each aetiological heading listed in Table 1.1 . • Polycystic kidney disease Drug history SSce c e n ari r i o 1. 1 • Prescribed A 75-75-year-oldyear-old womanwoman presents on a SaturdaySaturday to the • Over the counter emergencemergencyy department; struggling to cope at home, she reports a 4-week history ooff progressive abdominal swell- Social history ing. During tthishis time sshehe hhasas not bbeeneen eating wewellll anandd hhasas • Alcohol consumption (binges?) lost a sisignifignifi cant amount of weiweight.ght. On On examination examination she she • Travel history, including areas visited (rural is cachectic and jaundiced;jaundiced; she has ascites and an epi- or urban), activities engaged in (safaris, water gastric mass whichwhich is 5 cm in diameter,diameter, craggy in nature sports, etc.); did they take malaria prophylaxis anandd tettetheredhered to tthehe ununderlyingderlying structures. and have the recommended vaccinations? • Sexual history (protected, high risk partners?) Th is patient has been deteriorating for some time • Intravenous drug use (clean needles or and unfortunately ( but not uncommonly ) presented out shared?) of hours. She probably has advanced cancer, and this • Occupation (e.g. sheep farming, associated should be recognized by the admitting doctor from the with hydatid disease) outset; the diff erential diagnosis at this early stage is Past medical history wide and so this diagnosis should not be given to the patient without further confi rmation. • Tuberculosis • Diverticular disease • I n fl ammatory bowel disease History • Solid tumours or haematological malignancy A careful and comprehensive history is required. In Th e presence of ‘red fl ags’ requires the exclusion of particular: malignancy as a priority when planning investigations, bearing in mind that they can clearly be compatible Acute Medicine , ed. Stephen Haydock, Duncan Whitehead and Zoë Fritz. Published by Cambridge University Press. © Cambridge University Press 2015. 1 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-63357-5 - Acute Medicine: A Symptom-Based Approach Edited by Stephen Haydock, Duncan Whitehead and Zoë Fritz Excerpt More information Chapter 1: Abdominal mass/hepatosplenomegaly Table 1.1 Common and important causes of an abdominal Mechanical Intestinal distension mass by aetiology obstructive • Obstruction Aetiology Diagnosis • Constipation Renal enlargement Neoplastic Malignant • Hydronephrosis (severe) Primary malignancy Bladder • Pancreatic • Urinary retention • Colorectal • Hepatocellular carcinoma Degenerative Hernia • Gastric • Umbilical • Renal • Paraumbilical • Ovarian • Spigelian • Endometrial Infl ammatoryPancreatic pseudocyst Secondary/metastatic disease Hepatomegaly • Hepatic metastasis • Sarcoidosis • Lymphadenopathy (testicular spread to • Early cirrhosis with portal hypertension para-aortic nodes) (with splenomegaly) • Splenomegaly (CML) • Non-alcoholic steatohepatitis • Peritoneal spread Splenomegaly Benign • Sarcoidosis • Uterine fi broids • Systemic lupus erythematosus • Lipoma (anterior abdominal wall) Metabolic Hepatomegaly Infective Abscess • Amyloidosis • Diverticular Iatrogenic Renal transplant (right or left iliac fossa mass • Appendix with scar overlying) • Empyema of the gallbladder (may Implants progress from cholecystitis) • Buscopan pump (used in multiple • Crohn’s disease sclerosis) • Liver abscess (most commonly • Gastric pacemaker caused by ascending pathogens from Embedded peritoneal dialysis catheter biliary tract) (inserted ready for externalizing when Hepatomegaly dialysis is required) • Malaria Incisional hernia • Leptospirosis Idiopathic Splenomegaly • Viral hepatitis • Idiopathic thrombocytopenic purpura Splenomegaly Physiological Pregnancy • Immune hyperplasia (bacterial endocarditis, EBV, etc.) Vascular Abdominal aortic aneurysm Hepatomegaly • Congestion (right heart with other aetiologies: a patient with a liver abscess failure/tricuspid regurgitation, may be will develop anorexia and lose weight, so initially it pulsatile) is important to keep an open mind and equally open • Budd–Chiari syndrome (hepatic vein diff erential diagnosis. Try not to increase the patient’s occlusion, normally by thrombus) anxieties at this early stage . Splenomegaly • Portal hypertension (liver cirrhosis) Inherited Renal Examination • Autosomal dominant polycystic kidney Perform a full examination of the patient, including: disease (ADPCKD) respiratory, cardiovascular and neurological exami- Hepatomegaly nations alongside the abdominal examination. Many • Riedel’s lobe (normal variant) pathologies resulting in an abdominal mass or orga- • ADPCKD with hepatic cysts (♀ >♂ ) nomegaly will have manifestations in other systems 2 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-63357-5 - Acute Medicine: A Symptom-Based Approach Edited by Stephen Haydock, Duncan Whitehead and Zoë Fritz Excerpt More information Chapter 1: Abdominal mass/hepatosplenomegaly as well. Th ere are oft en some subtle clues to the aeti- • Raised infl ammatory markers suggest infection, ology which may be present, so take care to examine for but are signifi cantly raised in IBD and frequently anaemia, splinter haemorrhages and lymphadenopathy . elevated with neoplasia. Once organomegaly or a mass has been identifi ed, • Low albumin, raised platelet count and anaemia examine it carefully and clearly document: all suggest neoplasia, but are compatible with • site (consider which organ it may be, or is signifi cant infl ammation of other causes. associated with) • Tumour markers should be used with caution in • size assisting initial diagnosis as none are specifi c for a • shape given malignant disease; they are more useful for • nature (smooth or craggy, soft or fi rm) monitoring response to treatment: • mobility • CA19-9, pancreatic cancer • reducibility (if it could represent a hernia) • CA125, ovarian cancer • appearance of the overlying skin (scar, stretch • CEA, colorectal cancer . marks). In addition a digital rectal examination and urinalysis Radiological imaging are essential elements of the clinical examination which Always give careful consideration to deciding the must not be forgotten . most appropriate initial imaging modality ( Table 1.2 ). Aft er completing the examination you may have fi nd- Th e aim is to gain accurate diagnostic information in ings that require you to go back and revisit the history. the shortest time frame with the minimum of risk to the Patients rarely mind a few additional questions asked patient . Th e modality selected will depend upon the dif- aft er or during the examination; it shows their physician ferential diagnosis formed, which guides the question is interested and considering their case carefully . you are asking of the imaging : • Has this well 45-year-old woman with nodular Investigation hepatomegaly whose grandfather died of renal failure got ADPCKD with multiple liver cysts? Blood tests • Ultrasound scanning will rapidly answer this question with virtually no risk to the patient . • FBC • In the 53-year-old male smoker who drinks 50 • U&E units of alcohol a week, who has lost 6 kg of weight • LFT over 2 months and examination revealed craggy • CRP hepatomegaly and anaemia, the question needing • Calcium an answer is ‘has he got cancer?’ and if so ‘what is • Clotting screen the primary and has it metastasized?’ • Tumour markers (use selectively, with caution) • CT chest, abdomen and pelvis with contrast is • Blood fi lm (if haematological malignancy is the fi rst-line imaging modality of choice, giving suspected) diagnostic and prognostic information, also • If infective symptoms clarifying potential biopsy sites for histological • Blood cultures confi rmation. • Urine cultures It is not the case that USS is more sensitive for • Stool culture (if diarrhoea) liver lesions than CT, but it does avoid exposing the • According to history; malaria screening, HIV, patient to the risks of ionizing radiation and iodinated hepatitis serology, CMV, EBV contrast . Th ese can be helpful in narrowing the diff erential diag- nosis and identifying the unwell from the clinically sta- Surgical exploration ble patient. Despite modern imaging modalities, in certain cir- • Anaemia is never normal and always has a cause or cumstances surgical exploration by laparotomy or causes; it should prompt haematinics (B12 , folate, more frequently laparoscopy into the cause
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