Abdominal Lump

History

-          38 years, male

-          Low socio-economic status

-          Severe pain upper abdomen- since 3 days- sharp stabbing, radiating to back, associated with recurrent vomiting(gastric content), passage of black tarry stools(fowl smelling).

-          Similar episode 2 months back that subsided following medications for few days.

-          Known alcoholic- 15 years , >200ml/day

-          Patient gives history of malena- 3 days, bulky greasy stools- 1month.

-          No H/O jaundice, haemoptysis, haematochezia, IV drug abuse.

-          Past history- no history of T.B., DM, HTN, CHD, CVD, Asthma.

-          Personnel History: smoker, alcoholic

Examination findings:

-          General Physical Examination(GPE)- patient was conscious, co-operative, oriented to time place and person and lying in his bed. General condition was poor, hydration was poor and performance score was 70% by karnofsky scale. Pallor++, icterus-, cyanosis-, edema-, clubbing-, peripheral lymphadenopathy-.

-          PR=106/min, Rt arm, supine, normal volume, no Radio-Radial or Radio-Femoral delay.

-          BP=100/60 mm Hg,

-          RR= 20/min.

-          Hair, skin and oro dental hygiene poor.

-          Chest: reduced air entry at bases; Lt>Rt with crepitation.

-          CVS: S1 S2 normally heard

-          CNS: NAD

Abdominal Examination:

Inspection-

-          Skin normal

-          No dilated vein or scar

-          Umbilicus is displaced down(25cm vs 18cm), inverted

-          Decreased movement with respiration

-          Apparent fullness in upper part of abdomen more in central part

-          All hernia sites are free

Palpation-

-          Temperature normal

-          Tenderness over (epigastrium, Rt & Lt hyponchondrium & Umbilical region)

-          No guarding, no rigidity, no rebound tenderness

-          Vague lump 25*15cms extending from – Rt & LT hypochondrium, epigastrium & umbilicus

-          Smooth surface and soft firm in consistency, no organomegaly.

Percussion:

-          Dullness, moderate ascites.

Auscultation:

-          Bilateral sluggish

Case summary:

-          A 38 years chronic alcoholic male

-          Epigastric lump probably pseudocyst pancreas in acute over chronic pancreatitis

Pseudocyst

-          Retroperitoneal

-          It does not move on respiration

-          It is fixed in its position

-          It does not fall forward on tilting

Investigation:

X ray-  

-          Pleural effusion more on the left side

USG abdomen-

CECT Abdomen-

-          Sensitivity of CT is higher for retroperitoneal masses

-          Delineates lymph node status

-          Vessel status

-          Pancreas visualized better

Balthazar’s CT scoring:  

Fallacies of Balthazar’s CT scoring-

-          It’s only a imaging modality

-          Doesn’t include clinical scenario

-          Doesn’t consider multiple organ failure

APACHE II SCORE:

APACHE O: - 

Factors leading to poorer outcome in pancreatitis-

-          Age

-          Alcohol

-          Obesity

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