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Abdominal Masses

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DavidChen on Oct 14, 2009 Says :

May I get these slides

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Notes

Show Notes

Slide 1 :

Abdominal Masses Liver Spleen Pancreas Retroperitoneum Adrenal Gland

Slide 2 :

Hepatomegaly Liver Enlargement

Slide 3 :

Causes of Hepatomegaly Metabolic (Wilson’s Dz, Gaucher Dz, Niemann-Pick Dz, Weber-Christian Dz, Galactosemia, Amyloidosis, Fatty Infiltration, Hemachromatosis, Hurler’s Dz) Infectious (ABSCESS, ECHINOCOCCAL CYSTS, Schistosomiasis, Histoplasmosis, Mononucleosis, Hepatitis, tb, malaria, sarcoid, HIV) Tumors (BENIGN, HCC, METASTATIC) Miscellaneous (CHF Hepatic Congestion, Polycystic Liver Disease)

Slide 4 :

Liver Evaluation Liver Function Tests Ultrasound CT Scan Radionuclide Scan Liver Biopsy

Slide 5 :

Liver Function Tests: Nonspecific and Poor Sensitivity Bilirubin: conjugation vs biliary excretion Transaminases: hepatocyte necrosis Alkaline Phosphatase/GTT: biliary obstruction or cholestasis vs hepatic infiltration Albumin & Prothrombin Time: synthetic function of the liver

Slide 6 :

Ultrasound: Fast, Convenient, and Safe Advantages Avoids Radiation Exposure & IV Contrast Excellent for Cystic Lesions (fluid interface) Allows Assessment of Biliary Tree Useful as Adjunct in Image-Guided Procedures Disadvantages Operator Dependent Less Sensitive than CT Scan for Most Things Intraoperative Ultrasound More sensitive for depth of lesions & useful for operative decision-making

Slide 7 :

CT Scan: Imaging Modality of Choice Advantages Best Sensitivity (lesions as small as 1 cm) Assesses Entire Abdomen Vascularity of Lesions Assessed by Phases Techniques to Enhance Sensitivity via SMA Injection Disadvantages Requires Radiation Exposure & IV Contrast

Slide 8 :

Radionuclide Scanning: Rarely Used Tc-99 Colloid Scan: liver masses visualized as cold nodules on scanning Tagged RBC Scans: diagnosis of hemangiomas 18-F Glucose PET Scans: insensitive study without utility in evaluating liver

Slide 9 :

Liver Biopsy Indications Chronic Liver Disease: etiology & staging Diagnosis of Mass Lesion Techniques Percutaneous Image-Guided (mass lesion) Laparoscopic Transjugular Intraoperative

Slide 10 :

Benign Hepatic Tumors

Slide 11 :

Case #1 52 y/o woman from Beverly Hills comes to your office with the results of a total body CT Scan paid out of pocket and demands that you take care of her problem. The image is shown

Slide 12 :

What is the next step? A) Schedule her for surgical exploration & possible resection depending on intraop findings B) Contact interventional radiology about a CT-Guided Biopsy of these lesions C) Tell her that she’s in no danger and “Don’t Worry, Be Happy” D) Complete a history & physical examination E) Order additional imaging studies

Slide 13 :

Case #1 (continued) The patient says that for years she has had postprandial epigastric pain. Her physical exam is unremarkable. What is the next step? A) Schedule elective surgical resection B) Order additional imaging C) CT-Guided Biopsy D) Reassurance & Observation E) Contact a specialist in Hepatobiliary Surgery

Slide 14 :

Benign Hepatic Tumors Hemangioma (capillary vs cavernous) Most Common Benign Hepatic Tumor Most Are Asymptomatic & Incidental Indications for Resection are Rare Workup Includes U/S, CT, MRI, RBC Scan Do Not Biopsy These Lesions Focal Nodular Hyperplasia 2nd Most Common Benign Tumor Incidental Finding Requring No Treatment Workup Includes CT or MRI Showing “Central Scar” Hepatic Adenoma Related to OCP Use Risk of Rupture & Malignant Transformation Pregnancy & OCP Use should be Avoided Once Diagnosted Rx: Resection unless Ruptured (embolize)

Slide 15 :

Benign Hepatic Tumors Central Scar: FNH Hepatic Adenoma

Slide 16 :

Case #2 23 y/o male recently returned from a backpacking trip through Central America. Over the last two weeks, he has had fevers, RUQ abdominal pain, and early satiety. He is seen in the ER & a CT Scan is Ordered.

Slide 17 :

Case #2: What is the next step? A) Schedule the patient for immediate exploration & surgical drainage B) Contact Interventional Radiology Regarding a Percutaneous Drainage C) Start Antibiotics against GI Flora D) Send Stool cultures & antibody titers E) Turf the Patient to Medicine for Admission

Slide 18 :

Cystic Lesions of the Liver Liver Abscesses (Pyogenic vs Amebic) Diagnosis by CT Scan, History, U/S, Serology Pyogenic: Drainage & Antibiotics Amebic: Long-Term Metronidazole Hydatid Cyst Asymptomatic vs Mass Effect Risk of Rupture & Anaphylaxis Diagnosis by CT Scan & U/S Treated by Surgical Closed Aspiration & Cyst Removal Liver Cysts / Degenerative Bile Ducts Simple Cysts Cystadenomas / Cystadenocarcinomas of Bile Ducts Polycystic Kidney Disease

Slide 19 :

Cystic Liver Lesions Pyogenic Liver Abscess Hydatid Cyst

Slide 20 :

Case #3 A 60 y/o HBV+ Male Presents with a 20 pound weight loss & a palpable mass in the RUQ. Alpha-Fetoprotein level is elevated. CT Scan is shown.

Slide 21 :

Case 3: What is the next step? A) Schedule elective exploration with possible hepatectomy B) Contact IR Regarding CT-Guided Biopsy C) Contact Hospice Regarding End of Life Care D) Estimate the Patient’s Hepatic Reserve E) Contact the nearest transplant center to list the patient for a liver transplant

Slide 22 :

Malignant Hepatic Lesions Hepatocellular Carcinoma Risk Factors: HBV>HCV>Alcohol Symptoms: RUQ Pain, Weight Loss, Mass Diagnosis: CT Scan, AFP, Needle Biopsy Outcome Dependent on Hepatic Reserve, Not Stage of Tumor Transplant vs Hepatectomy vs Ablation Fibrolamellar Variant: younger patients, central scar, no background of cirrhosis, better outcomes Metastatic Tumors: most common, isolated colorectal metastases resectable Other Primary Hepatic Tumors: cholangiocarcinomas, hepatoblastomas, sarcomas, lymphomas

Slide 23 :

Splenomegaly Enlarged Spleen Hypersplenism=hyperfunctioning spleen excessively removing blood cells

Slide 24 :

Hypersplenism: Rapid, Premature Destruction of Blood Cells Anemia (weakness, Palpitations) Thrombocytopenia (bruising, nosebleeds, GI bleeding, hematuria) Leukopenia (infections, mucosal ulcers) Splenomegaly Causes: malaria, RA, TB, Polycythemia vera, hemolytic anemias, cirrhosis, lymphoma Diagnosis: CBC, CT Scan or U/S

Slide 25 :

Case #4 An internist refers a 45 y/o woman to you with menorrhagia and nosebleeds who was found on workup to have a platelet count of 10,000. The remainder of the CBC is normal as are her coagulation studies. What is the next step A) Schedule elective splenectomy B) CT Scan Abdomen C) Bone Marrow Biopsy D) Steroid Therapy E) Technetium Scan

Slide 26 :

Splenectomy for Hypersplenism Immune Thrombocytopenia Purpura (ITP) Autoantibodies to platelet membranes Bleeding Complications Medical Treatment: Steroids & IVIG Splenectomy Effective in 67-85% Hereditary Anemias (spherocytosis, elliptocytosis) Acute Sequestration Crises (sickle cell, thalassemia) Rare Splenic Tumors: lymphoma, leukemia

Slide 27 :

Case #4 (continued) The patient failed medical therapy and underwent an uneventful splenectomy. One year after surgery, she is seen in ER after complaining of high fevers, myalgias & headaches from a persistent cold. What is the next step? A) Start broad spectrum antibiotics B) Check coagulation studies and platelet count C) Pan-culture patient D) Admit her to a monitored bed E) Send her home with tylenol and robitussin

Slide 28 :

Hyposplenism Loss of Immune Function from the Spleen Phagocytosis of blood bourne pathogens Immunoglobulin, Properdin, Tuftsin (opsinins) Evidenced by Howell Jolly Bodies in Blood Smear Causes Surgical Splenectomy Functional Asplenia: sickle cell disease Overwhelming Postsplenectomy Sepsis Susceptibility to life-threatening sepsis from encapsulated bacteria Lifelong Prophylaxis with PCN during medical/dental procedures & Pneumococcal & Hflu vaccination

Slide 29 :

Complications of Splenectomy Early Complications Bleeding Pneumonia / Atelectasis Pancreatitis Subphrenic Abscess Late Complications Overwhelming Postsplenectomy Sepsis

Slide 30 :

Pancreatic Masses

Slide 31 :

Diagnostic Studies of the Pancreas Ultrasound Fast, Convenient Study Imaging of the Biliary Tree Distinguish Cystic from Solid Lesions CT Scan Highly Sensitive & Specific (95%) Special Pancreatic Settings with 3 Phases Useful for Determining Surgical Resectability ERCP useful for patients with obstructive jaundice when there is no mass by CT Scan Biopsy used to diagnose unresectable tumors or when neoadjuvant therapy is planned

Slide 32 :

Case #5 60 y/o male is discharged home after a bout of alcoholic pancreatitis. Three weeks after discharge he returns to the ER with abdominal pain and a palplable mass. Amylase is slightly elevated. A CT Scan is ordered. WBC is normal & patient is afebrile

Slide 33 :

Case #5: What is the next step? A) Exploration and Distal Pancreatectomy B) Contact GI Service for an ERCP C) Contact IR for percutaneous drainage of an abscess D) Observation & Repeat CT Scan in One Month E) Admission for Antibiotics, Bowel Rest and Possible TPN

Slide 34 :

Pancreatic Pseudocysts & Abscesses Pseudocyst: inflammatory fluid collections that become walled off Persistent Abdominal Pain after Pancreatitis Palpable Mass in 50% Diagnosis by History & CT Scan Spontaneous Resolution in 40%: < 6 weeks duration, < 4 cm in size, no chronic pancreatitis, normal pancreatic duct, single cyst Complications: Infection, Bleeding, Rupture Surgical Therapy: Percutaneous, Endoscopic, Open Cystenterostomy Abscess: infected necrotic pancreas Major Complication of Pancreatic Necrosis Diagnosed by CT Scan & Aspiration Indicated by Fever, Abdominal Mass, Nausea/Vomiting Treated by Drainage & Antibiotics

Slide 35 :

Pseudocysts vs Cystic Neoplasms

Slide 36 :

CT Scans of Pancreatic Tumors Cystadenoma of Pancreas Pancreatic Ca Islet Cell Tumor

Slide 37 :

Retroperitoneal Masses Abscesses: extending from renal, GI, hematogenous Hematomas: trauma, aneurysms, iatrogenic Fibrosis: idiopathic, obstructive uropathy Malignancy Organ-Related: Kidney, Adrenal, Colon, Panc Lymphoma Sarcoma: most common primary tumor Metastatic Lesions (i.e. Testicular) Germ Cell Neoplasms

Slide 38 :

Management of Retroperitoneal Neoplasms

Slide 39 :

Common Histologies of Retroperitoneal Sarcomas

Slide 40 :

Abdominal Carcinomatosis Metastatic Tumor Deposits on the Peritoneum and Greater Omentum Etiologies: GI (stomach > colon > pancreas) or GU (ovarian) or more rarely extraabdominal (breast) Pseudomyoma Peritonei: from ruptured ovarian or appendiceal adenocarcinomas with mucin-secreting metastatic deposits

Slide 41 :

Case #6 54 y/o man is involved in a high speed MVA and comes to HGH as a trauma activation. Trauma workup is negative for injury. A CT Scan of the abdomen is done which shows an incidental lesion.

Slide 42 :

Case 6: What is the next step? A) History and physical examination B) Schedule elective resection C) CT-Guided Needle Biopsy D) Blood and Urine tests E) Discharge from the trauma service with routine followup by the patient’s PMD

Slide 43 :

Adrenal Incidentoma Adrenal Masses: 0.7 to 4.3% CT Scans Differential Diagnosis Nonfunctioning Adenomas: 55-94% Functioning Tumors Pheochromocytomas Aldosterone-Secreting Adenomas (Conn’s Syndrome) Cortisol-Secreting Adenoma (Cushing’s Syndrome) Adrenocortical Carcinoma: large with characteristic CT appearance Metastatic Cancer (especially lung cancer) Other Tumors (myelolipoma, ganglioneuroma, adrenal cyst)

Slide 44 :

Management of Incidentaloma

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