Chapter 21.  Surgical Aspects of Abdominal Pain 203

3.Malrotation with midgut volvulus: A life-threatening surgical emergency in which the intestine becomes twisted as a result of malrotation of the intestine during fetal development. Because the consequences of malrotation associated with midgut volvulus may be catastrophic, prompt diagnosis and treatment are required to prevent mortality and short-gut syndrome.

4.Necrotizing enterocolitis (NEC): The most common disease process of the gastrointestinal (GI) tract of premature neonates that results in segmental or total bowel necrosis.

21.3  Treatment of Conditions

1.Nonsurgical conditions: Gastroenteritis, constipation, colic, and other extra-abdominal conditions require treatment directed at the underlying cause.

2.Surgical conditions: In general, prompt surgical intervention is required for pathologies associated with:

a.Vascular compromise (malrotation with volvulus, irreducible incarcerated hernias, nonreduced intussusception, adhesive bowel obstruction, solid organ torsion, and trauma)

b.Perforated viscus (acute appendicitis, NEC, Meckel’s diverticulum, trauma, and foreign bodies)

c.Acute hemorrhage (Trauma, Meckel’s diverticulum, and ectopic pregnancy)

21.4  Indications for Surgical Referral in Children with Abdominal Pain

1.Increasing abdominal pain with progressive clinical deterioration

2.Bilious vomiting

3.Involuntary abdominal guarding or rigidity

4.Rebound abdominal tenderness

5.Marked abdominal distension with tympany

6.Acute fluid or blood loss into the abdomen

204 J.A. Sandoval

7.Abdominal trauma

8.Abdominal pain without clear etiology

References

1.Acute abdomen. Semin Pediatr Surg 1997;6:57-111.

2.Ashcraft KW. Consultation with the specialist: acute abdominal pain. Pediatr Rev. 2000;21:363-367.

3.Leung AK, Sigalet DL. Acute abdominal pain in children. Am Fam Physician. 2003;67:2321-2326.

4.Mason JD. The evaluation of acute abdominal pain in children.

Emerg Med Clin North Am. 1996;14:629-643.

5.Buchert GS. Abdominal pain in children: An emergency practitioner’s guide. Emerg Med Clin North Am. 1989;7(3):497-517.

Chapter 22

Approach to Abdominal Masses

Kenneth W. Gow and Martin A. Koyle

Key Points

››Most abdominal masses originate from the retroperitoneum with the kidney accounting for more than half of the lesions.

››Most lesions in infants are benign and malignant in older children.

››Diagnostic imaging commonly begins with an ultrasound followed by a CT scan to characterize the lesion and determine the anatomical relationships.

22.1  Introduction

Pediatricians commonly see abdominal masses in their patient population. While most abdominal masses will not require surgery, it is estimated that 40% will.The key task for the clinicians is to determine which need further work-up. Most disorders originate from the retroperitoneum with the kidney accounting for more than half of the lesions. Only 10% will arise from intraperitoneal organs. While most lesions in infants are benign in nature (Fig. 22.1), there is a higher risk of malignancy in older children (Fig. 22.2). The method of determining which abdominal masses need surgical attention involves a thorough history and physical, followed by selected laboratory tests, and focused diagnostic imaging (Fig. 22.3).

P.P. Godbole et al. (eds.), Guide to Pediatric Urology and

205

Surgery in Clinical Practice, DOI: 10.1007/978-1-84996-366-4_22,

© Springer-Verlag London Limited 2011

206	K.W. Gow and M.A. Koyle
			Intraperitoneal − 20%
Flank − 65%			• GI Masses − 15%
• Renal − 55%			• Duplication
• Hydronephrosis			• Meconium ileus
• Polycystic kidney			• Mesenteric-omental cyst
• Mesoblastic nephroma			• Hepatobiliary − 5%
• Renal ectopic			• Hemangioendotheloma
• Renal vein thrombosis			• Hepatoblastoma
• Nephroblastomatosis			• Hepatic cyst
• Wilms tumor			• Choledochal cyst
• Nonrenal − 10%			• Hydrops of gallbladder

•Adrenal hemorrhage

•Neuroblastoma

•Teratoma

elvic − 15%

Hydrometrocolpos Ovarian cyst

• Sacrococcygeal teratoma

FIGURE 22.1.  The common causes of abdominal masses in infants.

		Intraperitoneal − 18%
		• GI Masses − 12%
		• Appendiceal abscess
	Flank − 78%
		• Congenital abnorm.
	• Renal − 55%
		• Other neoplasms
	• Wilms tumor
		• Hepatobiliary − 6%
	• Hydronephrosis
		• Hepatoblastoma
	• Cystic disease
		• Hepatocellular ca
	• Nonrenal − 23%
		• Choledochal cyst
	• Neuroblastoma

•Teratoma

•Other neoplasms

Pelvic − 4%

Ovarian cyst

Hydrometrocolpos

FIGURE 22.2.  The common causes of abdominal masses in children and adolescents.

History, Physical, Lab Tests

ABDOMINAL MASS

Abdominal Radiograph

Bowel Obstruction

Calcifications

REFER

Bowel gas displacement

Consider: BE or UGI

Abdominal Ultrasound

FLANK

INTRAPERITONEAL

PELVIC

Renal

Adrenal

Other

Cystic

Solid

Complex

Solid

Cystic

Pregnancy

Cystic

Solid

Cystic

Solid

Cystic

Solid

Omental,Choledochal Urachal, P.Sten.,

Mesenteric

Cyst

Duplication IBD,

Intussusception

Distended

NUCLEAR SCAN, VCUG

CT SCAN OF ABDOMEN

CT SCAN OF ABD.

Bladder

Nonfunctional

Functional

Mesoblastic

Adrenal

NB,

Cystic

Teratoma,

Hemangioma,

HB,

Pancreatic

Appy Meconium Sacro-

Ovarain Cyst,

Nephroma,hemorrhage Pheo.

Hygroma,

Sarcoma,

HIDA

Organomegaly,

HCC,

Pseudocyst Abscess

Cyst

Coccygeal Hydrometro-

Wilms Tumor,

Abscess

Pancreas,

Lymphoma,

Teratoma,

Colpos,

MCDK,

CCSK, MRTK

Lymphoma,

Mets

Sarcoma

Ant.

RCC

Neuroblastoma

UPJO,

Meningo-

No

Duplication

+/- Reflex

Myelocele,

Ureterocele reflux

Rectal

duplication

PUV,

UPJO,

Stricture

UVJO,

Duplication

PEDIATRIC GENERAL SURGERY REFERRAL

Duplication,

1°/2

°?

ureterocele,

PCDK

Follow,

Follow,

Follow,

Fo low,

A/B,

OR

Follow

OR

OR

OR

OR

OR

OR

OR

OR

OR

Cath. Mx

OR

OR

OR

OR

OR

PED. UROLOGY REFERRAL

Abbreviations: BE – Barium enema; UGI – Upper gastrointestinal contrast study; IBD – Inflammatory bowel disease; MCDK – Mu ticystic dysplastic kidney; UPJO– Ureteropelvic junction obstruction;

UVJO – Ureterovesical junction obstruction; PCDK – Polycystic disease of the kidneys; PUV – Posterior urethral valves; CCSK – Clear cell sarcoma of the kidney; MRTK – Malignant rhabdoid tumor the kidney; RCC – Renal cell carcinoma; NB – Neuroblastoma; Pheo. – Pheochromocytoma; HIDA – Hepatobiliary iminodiacetic acid scan; HB – Hepatoblatoma; HCC – Hepatocellular carcinoma; Appy – Appendiceal; OR – Operative management; A/B – Antibiotics; Cath – Catheterize; Mx – Management

FIGURE 22.3.  A flowchart for work-up of abdominal mass in pediatric patients.

207 Masses Abdominal to Approach  .22 Chapter