Abdominal mass

Abdominal mass
This infant has massive hepatomegaly due to metastatic neuroblastoma. Intra-abdominal pressure is partially relieved by a silastic pouch. Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

An abdominal mass is any localized enlargement or swelling in the human abdomen. Depending on its location, the abdominal mass may be caused by an enlarged liver (hepatomegaly), enlarged spleen (splenomegaly), protruding kidney, a pancreatic mass, a retroperitoneal mass (a mass in the posterior of the peritoneum), an abdominal aortic aneurysm, or various tumours, such as those caused by abdominal carcinomatosis and omental metastasis. The treatments depend on the cause, and may range from watchful waiting to radical surgery.

Features

Many abdominal masses are discovered incidentally during routine physical examination. When they present symptomatically, abdominal masses are most frequently associated with pain or digestive problems. However, depending on the cause, masses may be associated with other signs and symptoms, such as jaundice or bowel obstruction.

Diagnosis

The first steps in diagnosis are a medical history and physical examination. Important clues during history include weight loss, diarrhea and abdominal pain.

During physical examination, the clinician must identify the location of the mass, as well as characterize its location (usually specified in terms of quadrants). The mass should be assessed for whether it is rigid or mobile. It should also be characterized for pulse or peristalsis, as these would help in further identifying the mass.

Routine blood tests are usually the next step in diagnosis after a thorough medical history and physical examination. They should include a full blood count, blood urea nitrogen (BUN), creatinine, and liver function tests such as albumin, international normalized ratio (INR), partial thromboplastin time (PTT), serum amylase and total bilirubin (TBIL). If late-stage liver disease is suspected, then a serum glucose may be appropriate.

Physical Examination

• Associated symptoms:

  • Rectal bleeding
  • Weight change
  • Urinary symptoms
  • Fever
  • Changes in bowel habits

Abdomen

• Examine abdomen for areas of tenderness

Other

• Examine pelvis for areas of tenderness

Laboratory Findings

• Blood urea nitrogen (BUN)/creatinine
• Complete blood count (CBC)
• LFTs (liver function tests)
• Urinalysis
• Beta-human chorionic gonadotrophin

Electrolyte and Biomarker Studies

• Electrolytes
• Tumor markers (if concern is malignancy)
• Toxicology screen
• Blood culture (if concern is infection)

X Ray

• KUB (kidneys, ureters, bladder) x-rays could possibly reveal free intraperitoneal air, constipation or obstruction.

MRI and CT

• Abdominal CT with oral IV contrast will evaluate for bowel pathology, abscess, and hepatosplenomegaly

Other Diagnostic Studies

• Laparoscopy of the intra-abdominal cavity allows for direct visualization
• Colonoscopy helps in the diagnosis of bowel pathology
• Paracentesis with fluid evaluation.

Complete Differential Diagnosis of Causes of Abdominal Mass

In alphabetical order.

• Abdominal Aortic Aneurysm
• Abscess
• Actinomyces
• Acute pancreatitis
• Adrenal tumor
• Alveolar hydatid disease (parasite mass, most commonly involving the liver)
• Amyloidosis (hepatomegaly and splenomegaly)
• Aneurysms
• Ascites (localized ascites)
• Autoimmune pancreatitis (inflammatory mass)
• Bartonellosis (hepatomegaly and splenomegaly)
• Bezoar
• Biliary atresia
• Bladder distention
• Blind loop syndrome ( the mass is the loop of the bowel)
• Bowel obstruction (the mass is a loop of the obstructed bowel)
• Brenner tumor (ovarian tumor)
• Brucellosis (hepatomegaly and splenomegaly)
• Burkitt's lymphoma
• Carcinoid tumours
• Castleman's disease (hepatomegaly and splenomegaly)
• Cat scratch fever (hepatomegaly and splenomegaly)
• Cholangiocarcinoma
• Cholecystitis ( inflammatory mass, or abscess)
• Choledochal cyst
• Cholelithiasis ( a stone filled gallbladder can produces a painless right-upper-quadrant mass)
• Choriocarcinoma
• Chronic myelogenous leukemia (splenomegaly)
• Cirrhosis ( the liver itself or one significantly enlarged nodule) C66
• Colonic diverticulitis (inflammatory mass or peridiverticular abscess)
• Colorectal cancer
• Congenital hypertrophic pyloric stenosis
• Congenital megacolon (Hirschsprung's disease)
• Constipation (fecal mass or dilated colon)
• Crohn's disease ( abscess, loop of obstructed bowel, or inflammatory mass with or with out fistula)
• Cryptorchidism
• Dermoid cyst
• Desmoplastic small round cell tumor ( soft tissue sarcoma, usually multiple abdominal masses)
• Distal intestinal obstruction syndrome ( in patients with cystic fibrosis or pancreatic enzymes insufficiency)
• Ectopic pregnancy
• Endodermal sinus tumor
• Endometriosis
• Entamoeba histolytica (hepatomegaly and splenomegaly)
• Eosinophilic gastroenteritis ( rare presentation as an obstructing caecal mass)
• Extramedullary haematopoiesis (splenomegaly)
• Gallbladder benign tumors
• Gallbladder cancer
• Gallbladder empyema
• Gastrointestinal stromal tumor
• Gastroschisis ( other names paraomphalocele, laparoschisis, or abdominoschisis)
• Gaucher disease (splenomegaly)
• Germ cell tumor
• Hairy cell leukaemia (splenomegaly)
• Hamartoma
• Hemangioendothelioma
• Hemangiopericytoma
• Hepatic adenoma
• Hepatoblastoma
• Hepatomegaly
• Hernia
• Hirschsprung's disease (congenital megacolon)
• Histiocytosis X (splenomegaly)
• Hodgkin's lymphoma
• Hydatid cyst
• Hydronephrosis
• Intususception of the intestine
• kala-azar or Leishmaniasis (splenomegaly)
• Kaposi sarcoma
• Kidney cancer (including renal cell carcinoma)
• Krukenberg tumor (secondary ovarian malignancy whose primary site arose in the gastrointestinal tract)
• Large bowel obstruction
• Leiomyoma
• Liposarcoma(retroperitoneal)
• Liver abscess
• Liver cancer, metastatic
• Liver cancer, primary (hepatocellular carcinoma)
• Liver granuloma
• Lymphogranuloma venereum
• Malaria (splenomegaly)
• Meigs syndrome (ovarian tumor)
• Mesenteric cyst
• Mesothelioma ( abdominal )
• Mucosal-associated lymphoid tissue lymphoma (MALTOMA)
• Mycobacterium tuberculosis (hepatomegaly and splenomegaly)
• Myelofibrosis (splenomegaly)
• Nephroblastoma
• Neurilemmoma
• Neuroblastoma
• Neuroendocrine tumor
• Neurofibromatosis
• Non-Hodgkin lymphoma
• Obesity ( subcutaneous fat mass)
• Oesophagostomiasis ( a parasitic intestinal helminth that develops in the colonic wall, causing pus-filled granulomas)
• Ogilvie's Syndrome (dilated loop of bowels)
• Oncocytoma (of the kidney)
• Ovarian cancer
• Ovarian cyst
• Palpable gallbladder (Courvoisier's sign)
• Pancreatic abscess
• Pancreatic cancer
• Pancreatic islet cell tumors
• Pancreatic pseudocyst
• Pelvic inflammatory disease (abscess)
• Pelvic kidney
• Peritoneal adhesions
• Phaeochromocytoma
• Plexosarcoma
• POEMS syndrome
• Polycystic kidney disease
• Pregnancy
• Prune belly syndrome
• Pseudomyxoma peritonei
• Psittacosis (hepatomegaly and splenomegaly)
• Pyloric stenosis
• Rectus sheath hematoma
• Relapsing fever
• Renal cell carcinoma
• Renal oncocytoma
• Renal transplantation (the mass is the transplanted kidney)
• Rhabdoid tumor
• Riedel lobe of liver (sessile accessory lobe of the liver, a normal variant)
• Sacrococcygeal teratoma
• Sarcoidosis ( granulomatus mass, hepatomegaly, or splenomegaly
• Sickle cell crisis (abdominal / sequestration)
• Sister Mary Joseph nodule
• Small bowel lymphoma
• Small bowel obstruction
• Small intestine cancer
• Spleen lymphoma
• Splenomegaly
• Splenosis (autotransplantation of splenic tissues, usually after splenic rupture)
• Stomach cancer
• Syphilis(congenital)
• Tertiary syphilis (hepatomegaly and splenomegaly)
• Toxic megacolon
• Toxoplasmosis(congenital)
• Transitional cell carcinoma (bladder)
• Urachal cyst (a sinus remaining from the allantosis during embryogenesis)
• Ureteropelvic junction obstruction (pediatric hydronephrosis and palpable kidneys)
• Urine retention (distended bladder)
• Uterine enlargement
• Uterine leiomyoma (fibroids)
• Varicocele
• Vermiform appendix
• Visceral larva migrans
• Volvulus (twisted piece of the gastrointestinal tract)
• Wandering spleen
• Wilm's tumor (pediatric renal tumor)
• Yersinia enterocolitica (inflammatory mass, lymphoid mass, or Intususception of intestine)

Complete Differential Diagnosis of Causes of Abdominal Mass

Cardiovascular	*Abdominal Aortic Aneurysm
Chemical / poisoning	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	Acute pancreatitis, Ascites, Autoimmune pancreatitis, Bezoar, Biliary atresia, Blind loop syndrome, Bowel obstruction, Cholangiocarcinoma, Cholecystitis, Choledochal cyst, Cholelithiasis, Cirrhosis, Colonic diverticulitis, Congenital hypertrophic pyloric stenosis, Congenital megacolon, Constipation, Crohn's disease, Distal intestinal obstruction syndrome, Gastroschisis, Hepatomegaly, Hirschsprung's disease, Liver granuloma, Palpable gallbladder (Courvoisier's sign, Pancreatic pseudocyst, Pyloric stenosis, Riedel lobe of liver, Splenosis, Toxic megacolon, Urachal cyst, Vermiform appendix, Volvulus, Wandering spleen, Yersinia enterocolitica
Genetic	No underlying causes
Hematologic	No underlying causes
Iatrogenic	No underlying causes
Infectious Disease	Abscess, Actinomyces, Alveolar hydatid disease, Bartonellosis, Brucellosis, Cat scratch fever, Entamoeba histolytica, Gallbladder empyema, kala-azar, Leishmaniasis, Kaposi sarcoma, Liver abscess, Liver granuloma, Lymphogranuloma venereum, Malaria, Mycobacterium tuberculosis, Oesophagostomiasis, Pancreatic abscess, Pelvic inflammatory disease, Psittacosis, Relapsing fever , Syphilis, congenital, Tertiary syphilis, Toxoplasma, congenital, Yersinia enterocolitica
Musculoskeletal / Ortho	No underlying causes
Neurologic	No underlying causes
Nutritional / Metabolic	No underlying causes
Obstetric/Gynecologic	Choriocarcinoma, Ectopic pregnancy, Endometriosis, Meigs' syndrome, Pelvic inflammatory disease, Pregnancy, Uterine enlargement, Uterine leiomyoma
Oncologic	Adrenal tumor, Brenner tumor, Burkitt's lymphoma, Carcinoid tumours, Cholangiocarcinoma, Choriocarcinoma, Chronic myelogenous leukemia, Colorectal cancer, Desmoplastic small round cell tumor, Endodermal sinus tumor, Gallbladder benign tumors, Gallbladder cancer, Gastrointestinal stromal tumor, Germ cell tumor, Hairy cell leukaemia, Hamartoma, Hemangioendothelioma, Hemangiopericytoma, Hepatic adenoma, Hepatoblastoma, Histiocytosis X, Hodgkin's lymphoma, Kaposi sarcoma, Kidney cancer, Krukenberg tumor, Leiomyoma, Liposarcoma, Metastatic Liver cancer, Primary Liver cancer, Meigs syndrome, Nephroblastoma, Neurilemmoma, Neuroendocrine tumor, Non-Hodgkin lymphoma, Oncocytoma, Ovarian cancer, Pancreatic cancer, Pancreatic islet cell tumors, Phaeochromocytoma, Plexosarcoma, POEMS syndrome, Pseudomyxoma peritonei, Renal cell carcinoma, Renal oncocytoma, Rhabdoid tumor, Sacrococcygeal teratoma, Sickle cell crisis, Sister Mary Joseph nodule, Small bowel lymphoma, Spleen lymphoma, Stomach cancer, Transitional cell carcinoma, Uterine leiomyoma, Wilm's tumor
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal / Electrolyte	No underlying causes
Rheum / Immune / Allergy	No underlying causes
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	Bladder distention, Cryptorchidism, Hydronephrosis, Kidney cancer, Pelvic kidney, Polycystic kidney disease, Renal cell carcinoma, Renal oncocytoma, Renal transplantation, Transitional cell carcinoma, Urine retention, Varicocele, Wilm's tumor
Miscellaneous	No underlying causes

Treatment

• Immediately treat life-threatening causes (such as abdominal aortic aneurysms).
• Organomegaly typically resolves once the underlying etiology is treated.

Acute Pharmacotherapies

• Ogilvie's syndrome responds to decompression by IV neostigmine or by a rectal tube
• Constipation is usually treated with laxatives, increased dietary fiber and fluids, enemas.

  • Manual disimpaction is reserved for fecal impaction.
  • Stop use of offending medications.

• Masses caused by infections require antibiotics (and possible surgery)

Surgery and Device Based Therapy

• Several benign and malignant masses require surgical intervention
• Hirschsprung's disease often requires surgery.

Additional Resources

• MedlinePlus medical encyclopedia: Abdominal mass - An informative primer on abdominal masses and their common causes.
• First Principles of Gastroenterology: Abdominal Mass - This chapter discusses the basic approach to abdominal masses.

Acknowledgements

The content on this page was first contributed by Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]

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