University of Malaya Medical Programme

3.3

Surgical Causes of Abdominal

Masses in Neonates and Infants

Dr Anand Sanmugam
BSc.Med Sc.(UPM), M.D.(UPM), MRCS (Ire), M.Paeds. Surg (Malaya)
Paediatric Surgeon & Senior Lecturer
University of Malaya
Learning Objectives

• Understand the appropriate approach to paediatric patients presenting with

abdominal masses
• Adopt a systematic assessment process involving:-
• Detail hx taking
• Physical examination
• Understand the natural history of common pathologies presenting as abdominal
masses in children
APPROACH

How do I classify?

• Neonate vs infant vs child?

• Solid vs cystic?
• Benign vs maligant?
• Quadrant of abdomen?
• Organ / organ system ?
• Pathological process ?
APPROACH

• Do not be too rigid

• Approach cases with an open mind
• Be aware of :-
• The most common
• The uncommon
• The most ‘dangerous’ / Mass(es) requiring urgent
attention
History taking

• Age Neonate vs Child

Older children have higher risk of
• Timeline developing malignant masses
<2yrs – neuroblastoma / hepatoblastoma
• Rate of growth
• Origin
• Assoc. GI / GU sx
• Constitutional sx
• Antenatal hx.
• Pain
History taking

• Age
• Timeline / Rate of growth Slow growing vs rapidly growing
Slow growing – lesser tendency
• Origin to be malignant
• Assoc. GI / GU sx
• Constitutional sx
• Antenatal hx.
• Pain
History taking

• Age
• Timeline / Rate of growth
• Origin Anatomical location
• Assoc. GI / GU sx Likely underlying organ

• Constitutional sx
• Antenatal hx.
• Pain
History taking

• Age
• Timeline
• Rate of growth
• Origin
Clue with regards to origin of
• Assoc. GI / GU sx lesion – GI bleed / haematuria
• Constitutional sx Diarrhoea in neuroblastoma /
carcinoids
• Antenatal hx. Loco-regional lesion – extrinsic
compression
• Pain
History taking

• Age
• Timeline / Rate of growth
• Origin
• Assoc. GI / GU sx
• Constitutional sx Fever
LOA /LOW
• Antenatal hx. Lethargy
• Pain Anaemia
History taking

• Age
• Timeline / Rate of growth
• Origin
• Assoc. GI / GU sx
• Constitutional sx
Oligohydramnios / Polyhydramnios
• Antenatal hx. Mass location / origin
• Pain
History taking

• Age
• Timeline / Rate of growth
• Origin
• Assoc. GI / GU sx
• Constitutional sx
• Antenatal hx. Nature of pain – colicky / intermittent
• Pain Onset and progression of pain
Colicky intermittent pain –
Intussusception, volvulus
Physical examination

• Not easy in children

• Build rapport with parents
• Substitute examination couch with
parent’s lap
• Be patient
• Be thorough
Physical examination

• Complete general physical examination

• Check vital signs!
• Plot growth chart
• Spend adequate time with general inspection
Physical examination

• Inspection
Position child supine , look for protrusion, bulging, asymmetry,
overlying skin
• Palpation
Superficial followed by deep – ascertain tenderness + perform
necessary maneouvres
• Auscultation
Bowel sounds, bruit
• Percussion
Ascertain nature / content of mass, elicit guarding / tenderness
Investigations - Radiology

• Plain abdominal x-ray

• Ultrasound
• Computed tomography (CT) scan
• Magnetic resonance imaging (MRI
Investigations - Labs

• Full blood count

• Blood Urea / Serum electrolytes / Se Creatinine levels
• Urinalysis: Hematuria or proteinuria
• Tumour markers
a

• a
a

• a
Wilms Tumour - Introduction

• Nephroblastoma
• 2nd commonest paediatric intra-abdominal malignancy
• accounts for virtually all pediatric renal neoplasms.
• Higher in people of African descent
• Peak incidence is at 3 years of age
• Rare in children > 5 years
Wilms Tumour

• Alterations of genes responsible for

normal genitourinary development
• Associated conditions:-
• cryptorchidism
• double collecting system
• horseshoe kidney
• hypospadias.
Wilms Tumour - Presentation

• Asymptomatic abdominal mass /

abdominal distention.

Occasional symptoms:
• abdominal pain
• vomiting
• hematuria
• hypertension.
Wilms Tumour - Evaluation

• Smooth and firm mass

• Masses can be bilateral (5-10%)
• May present with gross abdominal distension
• An abdominal sonogram or CT scan shows a solid
intrarenal mass.
Wilms Tumour - Staging

I Limited to kidney; complete resection

II Extent beyond kidney, complete resection
III Unresectable, confined to abdomen, Lymph node
metastasis
IV Hematogenous mets (lung, liver, bone, brain)
or lymph nodes outside abdomen
V Bilateral renal involvement at diagnosis
Wilms Tumour - Treatment

• Surgery
• Chemotherapy
• Prognosis depends on metastasis and histology type
Neuroblastoma - Introduction

• Malignant tumour

• Arises from sympathetic nervous system :-

- adrenal medulla (38%)
- paravertebral sites of sympathetic chain
- abdomen (30%)
- chest (20%) and
- neck or pelvis.
Neuroblastoma

• Small, blue, round cell tumor of childhood.

• Younger than with children with Wilms tumor
(Average age is 18 months; 80% < 5 years)
• Male-to-female ratio is 1.3:1
 Neuroblastoma - Presentation

• Many clinical presentations related to the site of the primary

tumor, metastatic disease, and its metabolic tumor by-products.
• Presents with abdominal mass (frequently crossing midline)
• Abdominal pain, urinary obstruction, flushing, sweating, diarrhea
(caused by tumor secretion of vasoactive intestinal peptide)
Signs of metastatic disease:
• Anorexia,
• Malaise
• Site-specific symptoms from metastases (bone,skin, liver, or
central nervous system)
• Neuroblastoma can become metastatic to the retrobulbar region,
leading to rapidly progressive, unilateral, painless proptosis;
periorbital edema; and ecchymosis of the upper lid.
Neuroblastoma - Evaluation

• A firm, irregular, non tender mass is palpable in the

abdominal region.

• Other physical examination findings include:

o pallor
o subcutaneous nodules
o Hepatomegaly

• Urinary levels of catecholamine metabolites, are

elevated in 90% to 95% of patients

• CT : Identification of a solid adrenal or paraspinal

mass, which is calcified in 80% of patients.
Neuroblastoma - Treatment

• Treatment may include:-

• bone marrow transplantation
• chemotherapy
• radiation therapy
• surgical debulking or resection.
• The prognosis depends on:-
• the stage of the disease
• the age of the patient,
• the site of the primary tumor
• histology
Hepatoblastoma - Introduction

• Arises in an otherwise normal liver.

• Commonest malignant primary liver tumor in
infants and children
• Median age of diagnosis is 1 year
• Most patients are diagnosed by 2 years of age.
Hepatoblastoma - Presentation

Clinical picture :
• Most patients present with an enlarging abdominal mass.
• Rt lobe > Lt lobe (3x)
• bilobar involvement in 20%-30%,
• multicentric involvement in 15%

Less common symptoms are :-

• anorexia, weight loss, and pain.

Metastases at diagnoses occur in 10%-20% of patients with the lung being the
predominant site of meta
Hepatoblastoma - Diagnosis

• AFP 100,000-300,000 mcg/mL

Elevated AFP levels are not specific for hepatoblastoma,

but they provide an excellent marker for
• response to therapy
• disease progression
• detection of recurrent disease

• CT scan
Hepatoblastoma – Staging & Treatment

• Treatment
• Surgical resection
• Neo adjuvant chemotherapy
• Liver transplantation
Infantile Hypertrophic Pyloric Stenosis

• Narrowing of the pylorus

• Diffuse hypertrophy and hyperplasia of the antrum and
pylorus
• Presents at 3-5 weeks of life
• Occurs in males > females (esp 1stborn)
Infantile Hypertrophic Pyloric Stenosis

Symptoms
• Vomiting – described as projectile
• Bowel opening / stools reduced
• Hunger despite feeding
• Dehydration and failure to thrive
Examination
• Palpable olive like mass in RHC / epigastrium
• Visible peristalsis after feeding
Infantile Hypertrophic Pyloric Stenosis

• Blood tests + serum electrolytes

• Ultrasound
• Contrast X-ray
Infantile Hypertrophic Pyloric Stenosis

• IHPS is a medical emergency

• Correct dehydration and acid-base imbalances
• Ramstedt pyloromyotomy
Mesenteric Cyst

Definition :
o Abdominal cysts that may occur in any part of the mesentery from the duodenal
mesentery to the rectal mesentery
o Most frequently cysts are localized in small bowel mesentery (ileum in 60%) and
mesocolon (ascending colon in 40%).
Clinical picture :
o Mesenteric cysts rarely cause abdominal symptom, In symptomatic cases diverse
unspecific symptoms may occur most frequently present symptom is chronic
undefined abdominal pain.
Evaluation :
o Physical exam  palpable, partly movable and painless abdominal mass.
Treatment :
o Surgical enucleation of the cyst is therapeutic method of choice.
Choledochal Cyst - Introduction

o Cyst of the choledochal duct ( common bile duct ).

o 1 in 10.000-13.000 live births
o More common in females (3-4:1).
o Possible genetic influence, common with other anomalies
(congenital hepatic fibrosis, intrahepatic biliary cysts, and
polycystic kidney disease).
Choledochal Cyst - Presentation

• Mass.
• Jaundice.
• RHC pain.
 Choledochal Cyst – Classification

• Type I - Cystic or fusiform dilatation of the CBD

most frequent type (90-95% of the cases).

• Type II - Diverticulum of the CBD, with normal size CBD.

• Type III - Choledochocele, a cystic dilatation of the distal

intramural portion of the CBD, typically protruding into the
second portion of the duodenum.

• Type IV - Cystic or fusiform dilatation of the CBD associated

with cystic, fusiform, or saccular dilatation of intrahepatic
bile ducts, also termed form FRUSTE.

• Type V - Cystic, fusiform, or saccular dilatation of the

intrahepatic bile ducts associated with a normal CBD; may be
associated with hepatic fibrosis (referred to as Caroli
disease).
Choledochal Cyst - Treatment

Type I-IV:
o Cystojejunostomy
o Total Excision and Cystojejunostomy
o Biliary reconstruction can be performed with a Roux-en-Y
hepaticojejunostomy as high as possible, near the hilum of the liver.

Type V:
o Hepatic Lobectomy
Intussusception - Introduction

Segment of intestine invaginates into the adjoining

intestinal lumen.

Causes:-
• Obstruction
• Ischaemia
• Necrosis
• Perforation
 Intussusception - Introduction

Segment of intestine invaginates into the adjoining

intestinal lumen.

Causes:-
• Obstruction
• Ischaemia
• Necrosis
• Perforation
Intussusception - Presentation

• Severe intermittent abdominal pain that comes and goes (intermittent pain).
• Vomiting - non bilious or bilious
• Diarrhea, Fever, Dehydration , Lethargy
• Sausage shaped mass on palpation of abdomen
• Distended abdomen.
• Diarrhea, Fever, Dehydration , Lethargy.
• Stool mixed with blood and mucus (sometimes referred to as "currant jelly"
stool because of its appearance).

The classic triad: vomiting, abdominal pain, and passage of blood per
rectum occurs in only one third of patients.
Intussusception - Workup

• Routine blood investigations

• Abdominal X-ray
• Ultrasound of the abdomen
Intussusception - Treatment

• RESUS , RESUS an RESUS

• Parenteral antibiotics
• Saline or pneumatic reduction
• Surgery
THANKS!!