MASS IN EPIGASTRIUM
Rowan NewmanMoya McLeodEdgar MuganziMASS IN EPIGASTRIUMOBJECTIVESDiscuss causes of mass in epigastrium, with special reference to:Stomach CancerCarcinoma of Transverse ColonAortic AneurysmPancreatic Pseudo-cystDiscuss causes of retroperitoneal lymphadenopathyUnderstand clinical investigations used to diagnose these conditionsRelate conditions to USMLE high yield information
CAUSES OF MASSConsider whether the mass is as a result of:- Trauma- Infection/ Inflammation- Neoplasm- Blood- Endocrine- Degenerative- Congenital-Autoimmune- MetabolicCLINICAL EVALUATION OF MASSHistoryPhysical ExaminationLocationMotilityPulsatileFirmnessTexturePainClinical Investigations
CARCINOMA OF STOMACH Fifth most common cancer world-wide Most common; adeno-carcinomaMay be sarcoma or lymphoma Prevalent among Japanese, alcoholics, pernicious anemia Higher risk in males and individuals over 50 years old 60-90% of stomach carcinomas are attributed to H. pylori infectionH. pylori often causes MALT ( Mucosa Associated Lymphoid Tissue) lymphoma.MALT lymphoma accounts for 5% of gastric tumours
PRESENTATIONHistologySignet ring appearance of cellsCancer in most common in lesser curvature of stomachSymptoms:Stomach painBlood in stoolRapid weight loss for no reasonJaundiceHeart burnSimilar to PUD and GERDVirchows nodesSIGNET-RING CELLS
CARCINOMA OF STOMACHDiagnosis Gastroscopy and biopsy CT- Scan PET- Scan Endoscopic ultrasoundUSMLE QUES. HINTS 50 yr old man with 6 month history of abdominal pain which is associated with nausea and bloating, not related to meals. He has no retro-sternal burning sensation, however he has loss of appetite, 10 lbs weight loss in the past 3 months with enlarged left supra-clavicular lymph nodes.CT- SCAN OF STOMACH CARCINOMA
CARCINOMA OF TRANSVERSE COLONThird most common cancer in US Mainly adeno-carcinoma with polyps at early stage High incidence in 60-79 yrs age group Arises from pre-existing ulcerative colitis, polyposis syndrome, excess CHO, fat and red-meat intake and decrease protective micronutrient intake:Selenium, vitamin E, vitamin C, lycopeneFolate, methionine, vitamin B6, vitamin B12Characterised by perforation, fistulation and obstruction
COLONIC POLYP
CARCINOMA OF TRANSVERSE COLONScreeningScreening begins at different ages depending on the risk level of the individual:Average risk: 50 yrsModerate risk: 40 yrsHigh risk: 20-25 yrs (HNCPP gene carrier)Colon cancer cells of originTubular < tubulovillous < villousSymptoms Blood smeared stool, mucous in stool, abdominal pain
COLONIC TUMOUR OF VILLOUS ARCHITECTURE
NORMAL VILLOUS TISSUECARCINOMA OF TRANSVERSE COLONDiagnosis Abdominal CT- Scan Colonoscopy Barium enemaABDOMINAL CT-SCAN OF CARCINOMA
ANEURYSM OF ABDOMINAL AORTA Most common location is infra-renal Pulsatile mass palpated superior to umbilicus Mainly caused by hypertension or secondary to bacterial (salmonella) infection Associated with emphysema which increases MMP causing decrease in collagen levels
ANEURYSM OF ABDOMINAL AORTA More common in males > 60 yrs Major complication is aortic dissection (tears in the wall of aorta) Rupture triad of AAA are severe left plank pain followed by hypotension from internal blood loss into the retroperitoneum and a pulsatile mass on PEAtherosclerotic plaque can embolize
ANEURYSM OF ABDOMINAL AORTADiagnosis Abdominal Ultrasound CT- Scan MRIULTRASOUND
ABDOMINAL CT-SCAN
MRI OF ABDOMINAL AORTIC ANEURYSM
STENTING OF ANEURYSM
USMLE QUES. HINTS 59 yr old male presents to ER with sudden, severe and constant lower back pain, with a history of hypertension, hyperlipidemia and emphysema. On P/E a pulsatile mass was palpated superior to the umbilicus and a BP reading of 150/90 mmHg was recorded.PANCREATIC PSEUDO-CYST Collection of fluid in the lesser sac of the peritoneal cavity. There is no epithelial lining hence is not a true cystNormally occurs after pancreatitis or traumaContains necrotic tissue, blood, pancreatic secretions with walls of surrounding stroma.PANCREATIC PSEUDOCYST1/3 occur at the head of the pancreasOccurs in all age groups: children after trauma and high in men75-85% related to gall stone of alcoholSYMPTOMSBloating of abdomenFeverPalpable massScleral icterusPleural effusionJaundice (increase with size of pseudocyst)PHYSICAL EXAMINATIONTender abdomenPalpable massDifficulty eating and digesting foodDIAGNOSISSerum amylase- may be normal or raisedSerum bilirubin and liver function- raisedCystic fluid analysis: decreased CEA; decreased fluid viscosity; increased amylaseFluctuation test- PositiveX-Ray with barium meal to show positionPrognosis is goodIMAGINGAbdominal CT: large cyst cavity in and around pancreasMRI: differentiate between organized necrosis and pseudocyst- detect solid componentUltra SoundEndoscopy: planningn therapy and drainage
Complications and treatment Pancreatic abscessRupture- shock and hemorrhageCompress other organs
Treatment: may go away by itself or needs needle or surgical drainage under laparascope.CT-SCAN OF PANCREATIC PSEUDOCYST
RETROPERITONEAL LYMPHADENOPATHY Retroperitoneal space contains kidneys, adrenal glands, pancreas, nerve roots, lymph nodes, abdominal aorta and IVC Lymph nodes drain the organs in the space and also the testes, ovaries, fallopian tubes and uterus Malignancies of any of these organs can cause retroperitoneal lymphadenopathy Lymphoma of the nodes also
CT-SCAN OF R.P. LYMPHADENOPATHY
USMLE QUESTIONA 28-year-old man presents complaining of heaviness in his testicle for 2 weeks. He states that he feels as though his testicle is enlarged. The man has a temperature of 37.2C (98.9F), a heart rate of 60/min, and a blood pressure of 115/70 mm Hg. He has a normal abdominal examination with no palpable masses. The right testicle is noticeably larger than the left testicle. There are no discrete nodules. Testicular ultrasound is performed, followed by an orchiectomy. He is found to have a seminoma and a retroperitoneal lymph node that is enlarged at 1.8 cm. He is given a diagnosis of stage IIA testicular seminoma (T2N1M0). What additional treatment is needed?
(A) Contralateral orchiectomy(B) Platinum-based chemotherapy and bilateral orchiectomy(C) Prophylactic mediastinal radiation(D) Retroperitoneal lymph node dissection(E) Retroperitoneal radiation
REFERENCESMedbullets team. 2015,Feb 04. Abdominal aortic aneurysm. Retrieved from medbullet website http://www.medbullets.com/step2-3-cardiovascular/20031/abdominal-aortic-aneurysm (Goljan, 2014) intext refAbdominal aortic aneurysms images Retrieved from https://www.google.com.jm/searchhttp://emedicine.medscape.com/article/184237-overviewhttp://www.surgery.usc.edu/divisions/tumor/pancreasdiseases/web%20pages/PANCREATITIS/pancreatic%20pseudocys1.htmlhttp://my.clevelandclinic.org/health/diseases_conditions/hic_Pancreatitis/hic-pancreatic-cysts-and-pseudocysts
