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Case History

Image not available. A 45-year-old man presents with a vague history of feeling unwell, loss of appetite but no apparent loss of weight, and early satiety. Abdominal examination reveals an obviously distended abdomen with a large central non-tender mass.

What is the differential diagnosis?

What investigations can help to determine the nature of the mass and what imaging techniques might be useful?

What is the choice of definitive diagnostic test?

Background

What is the differential diagnosis?

Image not available. Most abdominal masses are usually detected incidentally during routine physical examination. An abdominal mass may not be detected by the affected person because most abdominal masses develop slowly. If there are symptoms, abdominal masses are most often associated with pain or digestive problems. However, depending on the cause, masses may be associated with other signs and symptoms, such as jaundice or bowel obstruction.

An abdominal mass can be a sign of an abscess, an aneurysm, or an enlarged organ (such as the liver, spleen or kidney). Differential diagnosis includes all abdominal benign and malignant tumours and metastatic tumours, although in the present case, emphasis should be given to malignant tumours given the patient's symptoms (Table 8.1).

Table 8.1Most common causes of abdominal mass

The first steps in diagnosis are a medical history and physical examination. Important clues during history include weight loss and gastrointestinal symptoms. During physical examination, the clinician must identify and characterize the location of the mass, as well as assess whether it is rigid or mobile. Also characterize the mass for pulse or peristalsis, as these would help in further identification.

Discussion

What investigations can help to determine the nature of the mass and what imaging techniques might be useful?

Image not available. Routine blood tests are usually the next step in diagnosis. They should include a full blood count and biochemistry (including serum amylase, total bilirubin and serum glucose). The tumour markers, βhuman chorionic gonadotrophin and α-fetoprotein, are useful to exclude treatable extragonadal germ cell tumours. Epithelial serum tumour markers (carcinoembryonic antigen (CEA), CA19–9), although not proved to have prognostic or diagnostic value, may be useful. Urine 5-hydroxyindoleacetic acid (5-HIAA) will help in the diagnosis of carcinoid tumours and serum hormone levels (insulin, gastrin, glucagons, vasoactive intestinal polypeptide [VIP], somatostatin) will help the differential diagnosis of neuroendocrine tumours.1

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