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MASS IN EPIGASTRIUM

Rowan Newman
Moya McLeod
Edgar Muganzi

OBJECTIVES
Discuss causes of mass in epigastrium, with

special reference to:


Stomach Cancer
Carcinoma of Transverse Colon
Aortic Aneurysm
Pancreatic Pseudo-cyst

Discuss causes of retroperitoneal

lymphadenopathy
Understand clinical investigations used to
diagnose these conditions
Relate conditions to USMLE high yield
information

CAUSES OF MASS
Consider whether the mass is as a result of:

- Trauma
- Infection/ Inflammation
- Neoplasm
- Blood
- Endocrine
- Degenerative
- Congenital
-Autoimmune
- Metabolic

CLINICAL EVALUATION OF
MASS
History
Physical Examination
Location
Motility
Pulsatile
Firmness
Texture
Pain

Clinical Investigations

CARCINOMA OF STOMACH
Fifth most common cancer world-wide
Most common; adeno-carcinoma
May 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 infection
H. pylori often causes MALT ( Mucosa Associated

Lymphoid Tissue) lymphoma.


MALT lymphoma accounts for 5% of gastric tumours

PRESENTATION
Histology
Signet ring appearance of cells

Cancer in most common in lesser curvature of

stomach
Symptoms:
Stomach pain
Blood in stool
Rapid weight loss for no reason
Jaundice
Heart burn

Similar to PUD and GERD


Virchows nodes

SIGNET-RING CELLS

CARCINOMA OF STOMACH
Diagnosis
Gastroscopy and biopsy
CT- Scan
PET- Scan
Endoscopic ultrasound

USMLE 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 supraclavicular lymph nodes.

CT- SCAN OF STOMACH CARCINOMA

CARCINOMA OF TRANSVERSE COLON


Third 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, lycopene
Folate, methionine, vitamin B6, vitamin B12

Characterised by perforation, fistulation

and obstruction

COLONIC POLYP

CARCINOMA OF TRANSVERSE
COLON
Screening
Screening begins at different ages
depending on the risk level of the
individual:
Average risk: 50 yrs
Moderate risk: 40 yrs
High risk: 20-25 yrs (HNCPP gene carrier)

Colon cancer cells of origin


Tubular < tubulovillous < villous

Symptoms
Blood smeared stool, mucous in stool,
abdominal pain

COLONIC TUMOUR OF
VILLOUS ARCHITECTURE

NORMAL
VILLOUS
TISSUE

CARCINOMA OF TRANSVERSE COLON


Diagnosis
Abdominal CT- Scan
Colonoscopy
Barium enema

ABDOMINAL 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 PE
Atherosclerotic plaque can embolize

ANEURYSM OF ABDOMINAL
AORTA
Diagnosis
Abdominal Ultrasound
CT- Scan
MRI

ULTRASOUND

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 cyst
Normally occurs after
pancreatitis or trauma
Contains necrotic tissue, blood,
pancreatic secretions with walls
of surrounding stroma.

PANCREATIC PSEUDOCYST
1/3 occur at the head of the

pancreas
Occurs in all age groups:
children after trauma and high
in men
75-85% related to gall stone of
alcohol

SYMPTOMS
Bloating of abdomen
Fever
Palpable mass
Scleral icterus
Pleural effusion
Jaundice (increase with size

of pseudocyst)

PHYSICAL EXAMINATION
Tender abdomen
Palpable mass
Difficulty eating and digesting food

DIAGNOSIS
Serum amylase- may be normal or raised
Serum bilirubin and liver function- raised
Cystic fluid analysis: decreased CEA;

decreased fluid viscosity; increased


amylase
Fluctuation test- Positive
X-Ray with barium meal to show position
Prognosis is good

IMAGING
Abdominal CT: large cyst cavity in

and around pancreas


MRI: differentiate between
organized necrosis and pseudocystdetect solid component
Ultra Sound
Endoscopy: planningn therapy and
drainage

Complications and treatment


Pancreatic abscess
Rupture- shock and hemorrhage
Compress 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 QUESTION
A 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

REFERENCES
Medbullets team. 2015,Feb 04. Abdominal aortic

aneurysm. Retrieved from medbullet website


http://www.medbullets.com/step2-3cardiovascular/20031/abdominal-aortic-aneurysm
(Goljan, 2014) intext ref
Abdominal aortic aneurysms images Retrieved from
https://www.google.com.jm/search
http://emedicine.medscape.com/article/184237-overview
http://www.surgery.usc.edu/divisions/tumor/pancreasdise
ases/web%20pages/PANCREATITIS/pancreatic
%20pseudocys1.html
http://my.clevelandclinic.org/health/diseases_conditions/
hic_Pancreatitis/hic-pancreatic-cysts-and-pseudocysts