Abdominal Masses in the Neonatal Period

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History Gathering

  • Oligo or polyhydraminos
  • Full-term
  • Prenatal US, amniocentesis, pigtail catheter
  • Family history

 

Physical Exam

  • Supine : shape, umbilicus, hernias
  • Mass: location, size, shape, texture, mobility, tenderness, solid, cystic, air filler
  • If distension attempt to relieve to improve exam: NG for obstruction, Crede cath for urinary retention
  • +/- rectal exam
  • other: chest hypoplasia (Potter’s), bulging hymen (hydrometrocolpos), skin (neuroblastoma)

 

Differential by location

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Flank Mass

  • Renal 55%
    • Hydronephrosis (most common)
      • Unilateral: UPJ or UVJ obstruction, aberrant renal artery, kink in ureter
      • Bilateral: bladder outlet obstruction (posterior valves or neurogenic bladder) dx: renal scintigraphy and voiding cystourethrogram
      • Tx: pyeloplasty, resect obstruction
      • Note: sever hydro can be detected in utero and treated with a uretero-amniotic shunt
    • Multicystic Kidney
      • Unilateral: multicystic dysplastic kidney
      • Bilateral
        • Autosomal recessive polycystic kidney, tx: dialysis, transplant
        • Autosomal dominant polycystic kidney presents later
    • Solid kidney tumor
      • Most likely mesoblastic nephroma (benign), concentric rings on US, resect
      • Wilm’s tumor rarely presents before 6m

 

  • Juxtarenal
    • Neuroblastoma; most common extracranial malignancy in early childhood, solid, fixed, retroperitoneal (adrenals), catecholamines (sweating, flushing)
      • Check urine homovanillic acid, vanillyl mandelic acid
      • AXR, US, CT (staging), bone marrow aspiration (look for bone mets)
      • Resection +/- chemo and radiation
      • Good prognostic factors: less than 1yo, stage, histology
      • 4S: stage 1-2 with dissemination to liver, skin (blueberry muffin spots), bone marrow; low riskNeuroblastoma-4_0.jpg
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    • Adrenal hemorrhage – rare, asymptomatic, no management required
    • Renal Vein Thrombosis – rare, hematuria, HTN, thrombocytopenia, US, anticoagulation only if bilateral or extending to IVC
    • Pulmonary Sequestration

 

  • Right Upper Quadrant
    • Liver and biliary tree
      • Hemangioendothelioma (aka infantile hepatic hemangioma) - +/- cutaneous hemangiomas, can by asymptomatic or cause AV shunting and CHF, can spontaneously regress
        • Part of Kasabach-Merritt syndrome: low platlets, consumptive coagulopathy, hemolytic anemia
        • Treat with steroids, IFN, embolization/resection, or transplant
    • Hepatoblastoma
      • Elevated AFP, associated with Beckwith Wiedermann (macrosomia, macroglossia, visceromegaly, omphalocele)
      • Resect, +/- neoadjuvant chemo
    • Hamartoma
      • Benign but associated with chromosomal abnl
    • Choledochal cyst – cystic dilation of bile ducts, asymptomatic or jaundice, resection and drainage of hepatic duct into intestine

 

  • Left Upper Quadrant
    • Splenic cyst – resect if large

 

  • Mid Abdomen
    • Intestinal
      • Pyloric stenois – “olive”, non-bilious emesis, pyloromyotomy
      • Intestinal duplication – cystic or tubular, communicating or non-communicating, often no symptoms but can cause pain, obstruction, bleed, volvulus
    • Intestinal lymphatic malformation (omental, retroperitoneal, mesenteric) – mobile mass, benign but can cause obstruction, resect
    • Meconium
      • Ileus – associated with CF, small bowel atresia
      • Plug
      • Obstruction of  prematurity
      • Peritonitis or pseudocyst (if perforation occurs)
      • Present as distention, doughy mass, ground glass on AXR
      • Water soluble contrast enema can be diagnostic and therapeutic

 

  • Mid Abdominal Wall
    • Fascial defects causing sub-cutaneous mass
    • Omphalocele and gastroschisis are not “masses” technically
    • Omphalomesenteric remanents: incomplete vitelline duct reabsorption
      • Meckles, omphalomesenteric sinus, cyst, fistula
      • Surgical repair

 

  • Pelvic
    •  Uterine
      • hydrocolpos, hydrometrocolpos, imperforate hymen, vaginal transverse septum or atresia (block secretions caused by placental hormones)

 

  • Ovarian
    • Cystic tumors – mobile, usually benign, if complex on US get markers, large cysts need to be excised or percutaneously drained
    • Urachal cyst – the allantois remains  and there is a connection between umbilicus and bladder – urine out umbilicus or a cyst
    • Teratoma – can cause hemorrhage, polyhydraminos, posterior perineal mass: surgery +/- chemo
    • Hernias and hydrocele
      • Inguinal – can incarcerate or strangulate, surgery
      • Hydrocele – observe 1 year

 

  • Groin mass
    • Girls: entrapped ovary
    • Boys: ectopic testicle

 

“The Neonate with an Abdominal Mass” JC Chandler MWL Gauderer, Pediatr Clin Nam 51(2004) 979-997