Epigastric Mass

In developing the differential diagnosis of an epigastric mass, one merely needs to visualize the anatomy of the epigastrium from skin to spine. The conditions are presented in outline form in Table 5, but the important conditions are emphasized in the following discussion.

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EPIGASTRIC MASS

	M	I	N	T
	Malformation	Inflammation	Neoplasm	Trauma
Abdominal Wall	Hernia	Cellulitis Carbuncles	Lipoma Sebaceous cyst	Contusion
Diaphragm	Hiatal hernia	Subphrenic abscess
Liver	Cyst Hemangioma	Abscess Hepatitis	Hepatoma Metastatic carcinoma	Contusion Laceration
Omentum	Adhesion Cyst	Peritonitis Tuberculoma	Metastatic carcinoma	Traumatic fat necrosis Hemorrhage
Stomach	Hypertrophic pyloric stenosis	Gastric ulcer Gastric dilatation Gastric syphilis	Gastric carcinoma	Hemorrhage Stab wound
Colon	Hirschsprung disease Intussusception Volvulus	Diverticulitis Toxic megacolon	Colon carcinoma Polyp	Contusion Laceration
Pancreas	Cyst Pseudocyst	Pancreatitis	Carcinoma of pancreas	Contusion
Retroperitoneal Lymph Nodes		Tuberculosis	Lymphoma Sarcoma Metastatic carcinoma
Aorta	Aneurysm
Spine	Lordosis Scoliosis	Tuberculosis Arthritis Osteomyelitis	Metastatic carcinoma Myeloma Hodgkin lymphoma	Fracture Herniated disc Hematoma

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1. Abdominal wall. Here the physician must consider ventral hernias, contusions in the wall, the xiphoid cartilage (which occasionally fools the novice), and lipomas or sebaceous cysts.
2. Diaphragm. A subphrenic abscess may be felt here.
3. Liver. The liver extends into the epigastrium and occasionally into the LUQ; thus, any cause of hepatomegaly may present as an epigastric mass.
4. Omentum. This may be enlarged by a cyst, a mass of adhesions, tuberculoma, or metastatic carcinoma.
5. Stomach. The acute dilatation in pneumonia or pyloric stenosis needs to be recalled. However, one usually thinks of carcinoma of the stomach or a perforated ulcer when this organ is visualized.
6. Colon. Carcinoma, toxic megacolon, or diverticulitis may cause a mass in this organ, but a hard chunk of feces also may do so.
7. Pancreas. Important conditions that must be considered here are carcinoma of the pancreas and pancreatic cysts. Occasionally, chronic pancreatitis may present as a mass.
8. Retroperitoneal lymph nodes. Lymphoma, retroperitoneal sarcoma, and metastatic tumor may make these nodes palpable.
9. Aorta. An aortic aneurysm may be felt, but more often the examiner is fooled by a normal or slightly enlarged aorta.
10. Spine. Deformities of the spine (e.g., lordosis) may make it especially prominent, but a fracture, metastatic neoplasm, myeloma, or arthritis may do the same.

Approach to the Diagnosis

The association of other symptoms and signs are very helpful in determining the origin of an epigastric mass. If there is jaundice, the mass is probably an enlarged liver. Fever and chills suggests a subphrenic abscess displacing the liver downward or an abscessed gallbladder. A mass associated with a history of anorexia and wasting suggests pancreatic or gastric carcinoma. A history of alcoholism suggests that the mass is an enlarged liver or pancreatic pseudocyst. Blood in the stool suggests carcinoma of the stomach or colon. A history of constipation would warrant a cleansing enema to rule out a fecal impaction before ordering an expensive workup. If the mass pulsates, one would consider an aortic aneurysm in the differential diagnosis.

The initial workup should include a CBC, urinalysis, chemistry panel, amylase and lipase levels, stool for occult blood, and flat and upright x-rays of the abdomen. If a presentation is acute, a general surgeon should be consulted to consider immediate exploratory laparotomy. If the development was more insidious and the patient is in no acute distress, a more systematic workup can be done at this point. Based on the results of the initial workup, one can proceed with an upper GI series, a barium enema, or ultrasonography of the gallbladder and pancreas. However, a more expeditious route to the diagnosis would be to order a CT scan of the abdomen. It is wise to consult a surgeon or gastroenterologist to help decide what method would be the most cost-effective and prudent.

Other Useful Tests

1. Liver function tests (cirrhosis or carcinoma of the liver)
2. Hepatitis profile (hepatitis)
3. Gastroscopy (gastric carcinoma)
4. Colonoscopy (colon carcinoma)
5. Peritoneal tap (metastatic neoplasm, peritonitis)
6. Laparoscopy (metastatic neoplasm)
7. Aortogram (aortic aneurysm)
8. Gallium scan (subphrenic abscess)
9. Liver biopsy (cirrhosis, neoplasm)
10. Liver–spleen scan (hepatomegaly)
11. Exploratory laparotomy
12. Bentiromide excretion test (chronic pancreatitis)

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MASS IN THE HYPOGASTRIUM

	M	I	N	T
	Acquired or Congenital	Inflammation	Neoplasm	Trauma
	Malformation
Skin	Sebaceous cyst	Abscess	Primary and metastatic tumors Lipoma	Contusion
Subcutaneous Tissue and Fascia	Ventral hernia	Cellulitis	Primary and metastatic tumors Lipoma Neurofibroma	Contusion
Muscle	Diastasis recti	Myositis		Contusion
Bladder	Diverticulum Obstruction Stone		Carcinoma of bladder or prostate Prostatic hypertrophy	Ruptured bladder
Transverse Colon	Diverticulum Volvulus Intussusception	Diverticular abscess Granulomatous colitis Toxic megacolon	Carcinoma of colon	Contusion Perforation
Uterus	Pregnancy Endometriosis	Endometritis Parametritis	Fibroids Endometrial carcinoma Cervical carcinoma Choriocarcinoma	Perforation Contusion
Tube and Ovary	Ectopic pregnancy	Tubo-ovarian abscess	Ovarian cyst (benign and malignant)	Perforation Rupture
Aorta	Aneurysm Leriche syndrome Arteriosclerosis			Perforation
Lumbosacral Spine	Spondylolisthesis Lordosis	Pott disease Osteomyelitis	Metastatic tumor	Herniated disc
Preaortic Lymph Nodes		Tuberculous adenitis	Metastatic carcinoma Hodgkin lymphoma	Herniated disc
Peritoneum	Obstruction of portal vein with ascites	Ascites from tuberculosis or gonorrhea	Metastatic carcinoma with ascites	Bloody ascites from perforation of viscus

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Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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