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T h e q u e s tio n s b e lo w s h o u ld h e lp
fo cu s the re ad in g o f th is a rtic le .
1.
W h a t o rg a n ac c o u n ts fo r th e m a -
jority
o f n eo nata l a b do m in a l m as s e s?
2 . W ha t
c a u s e s o f a b d o m in a l m as s e s
in n e w b o r n s ar e c o mm on ly a s s o ci-
a te d w ith a bn or m al c alc if ic atio ns ?
3 . W hic h im ag in g te c h n iq u e s a re g e n -
e ra lly m os t c o s t-e ffec tiv e w he n e v a l-
u a tin g a n e w b o rn w ith a n a b d o m in a l
m a s s ?
4 . W h a t a re th e a d v a n ta g e s a n d d is -
a d v a n ta g es o f a b do min al u ltra s o un d
w h en c o m pa re d w ith o th e r im a g in g
techn iques?
5 . W h a t is th e c u rre n t s ta tu s o f p re -
n a ta l m an ag em en t o f fe ta l a b d om in a l
m a s s e s ?
E D UC AT IO NA L O BJE C TIV E
4 .T h e p e d ia tric ia n s h o u ld h a v e
kn ow ledg e to m a ke a n
appropr ia te
ev a lua tion o f a n ew b orn m a le in -
fa n t w ith a le ft fla n k m a ss , d iffe r-
e n tia tin g a m on g h y d ro n e p h ro s is
(u re te ro pe lv ic ju nc tio n o b stru c tio n ,
v es ic o u re te ra l re flu x , u re th ra l o b -
s truc tion ), W ilm s tu m or, n e u r o -
b las to m a , m u lticy s tic d iseas e o f
th e k id n ey , ren a l ve in th ro m bo s is ,
a n d a d re n a l h em ato m a , an d d e-
v e lo p an ap p ro p ria te p lan fo r m an -
a g em en t (T o p ic s , 89 /90 ).
P IR 1 7 2 p e d ia tr ic s in re v ie w
#{149}
v o l. 1 1 n o . 6 d e c em b er 1 9 8 9
A b d o m in a l M a s s e s in th e N ew b o rn
M a rs h a ll Z . S ch w a rtz , M D ,* an d
D o n a ld B . S h a u l, M D t
T h e pre sen ce o f an ab do m in a l
m a ss in the ne on a ta l p e riod is com -
m o n , o ccu rrin g in a pp ro x im a te ly 1 in -
fa n t in 1 00 0 live b irth s . D e sp ite th is
re la tive ly h igh in c ide nce , th e fin d ing
o f an a bd om ina l m a ss in a ne on a te
ca n b e a la rm in g fo r bo th pa ren ts and
ph ys ic ian s . U n til rece n tly , the ide n ti-
fic a tio n o f a n a bd om ina l m a ss w as
m ade b y p hys ic a l s ig ns (ie , ab do m in a l
d is te n tio n , pa lp ab le m as s). H ow ev er,
in th e p as t de ca de , fe ta l u ltras ou nd
ha s b ec om e tech n ica lly re fine d a nd is
m o re w id e ly p rac tice d . A s a re su lt,
the p res en ce o f an a bd om ina l m as s
in the fe tus m ay be kno w n lo ng be -
fo re b irth , a llo w in g fo r the fo rm a tion
o f a sp ec ific d iag no s is an d trea tm en t
p lan . In a dd ition to fe ta l u ltras on og-
rap hy , a w id e a rray o f s op h is tic a ted
im ag in g te ch n iqu es h ave be co m e
a va ila b le to a id in the d iag no s is o f an
a bd om ina l m a ss . H o w eve r, in the
co s t-co nsc io us e nv iron m en t in w h ich
he a lth c a re m us t b e p rov id ed , it is the
ph ys ic ian ’s res po ns ib ility to e va lua te
a n a bd om ina l m a ss a s co s t e ffe c -
tiv e ly as p os s ib le . E arly co nsu lta tion
a m on g th e p ed ia tr ic ian , p ed ia tric ra -
* P ro fess o r, D ep t o f S u rge ry a nd Ped ia tr ic s ,
an d Ch ie f, D iv is ion o f P ed ia tr ic S u rg e ry , U n i-
v e rs ity o f C a lifo rn ia -D a v is , S choo l o f M ed i-
c in e, S a cr am e nto .
t
S urg ica l re s ide n t, D ep t o f S urge ry , U nive rs ity
o f C alifo rn ia -D av is , S ac ram en to .
d io log is t, p ed ia tr ic su rg eo n , an d , in
the ca se o f p rena ta l d ia gn os is , the
ob s te tr ic ia n can ex pe d ite th is p roc -
es s .
M an y a bd om ina l m a sse s a re o f the
n on su rg ica l v arie ty (ie , o rg an om eg aly
o r b la dd e r d is te n tion ). M o st m a sse s
re qu ir ing su rg ica l in te rve n tio n a re b e -
n ign (87% ), a nd the p ro gn os is fo r
ne ona tes w ith a n a bd om ina l m a ss is
good .
In th is a rtic le , w e w ill rev ie w the
va riou s ca us es o f an a bd om ina l m as s
in the ne w bo rn , p rov ide a d iffe ren tia l
d iag no s is b ase d o n th e p hys ica l fin d -
ing s , a nd de scribe an e xpe d itio us
ro u te to a rriv e a t a d e fin itive d iag no -
s is . In ad d itio n , ap p rop ria te in itia l
tre a tm en t w ill b e d isc uss ed .
IN IT IA L E V A L U A TIO N
E va lua tio n o f a n a bd om ina l m as s
in ne ona tes c an be fa c ilita ted b y a
p rac tica l u nde rs tan d ing o f the m o st
like ly d ia gn ose s a nd the ab ility to c a -
tego rize th e m a ss based o n sym p -
to m s, loca tio n , an d p hy s ic a l cha rac-
te ris tics . A rev ie w o f n eo na ta l a bd om -
ina l m a sse s ind ica tes th a t th e o rg an
or sy s tem o f o rig in a re a s fo llow s :
5 5% a re re na l, 1 5 % in vo lve th e g en -
ita l tra c t, 1 5% invo lv e th e ga s tro in -
te stin al tra ct, 1 0 % a re re tro pe rito ne al
(n on ren a l), an d 5 % invo lv e the live r,
b ilia ry tra c t, a nd sp lee n (F ig 1
).
A s
p art o f th e in itia l eva lu a tion , the p re s-
en ce o r a bs en ce o f s ym p to m s m a y
b e use fu l. Is the b ab y irr ita b le o r a
p oo r fee de r? Is e m es is (no nb ilio us o r
b ilious ) p re sen t? T h ese sym p tom s o r
s ig ns m igh t im plica te th e g as tro in tes-
tina l trac t as the o rig in o f the ab do m -
in al m ass .
T he find in gs du ring p hy s ica l ex -
am ina tion c an be he lp fu l in m a k in g a
te n ta tive d iag no s is . Is the m as s 10 -
ca te d in the flan k , m id ab do m en , o r
sup rap ub ic a rea ? D o es the m a ss fe e l
firm (so lid ) o r co m pre ss ib le (c ys tic )?
C a n the m a ss b e m ove d ea s ily o r is
it f ix ed in p os itio n? D o es the su rfac e
o f the m a ss fee l sm o o th o r irre gu la r?
Is th e re te nd ern ess ass oc ia te d w ith
pa lp a tion , su gg es ting in flam ma tio n o r
he m o rrh ag e? Is th e m a ss in d ica tive
o f ge ne ra liz ed en la rg em en t o f a sp e -
c ific o rg an (eg , h ep a tom e ga ly o r
sp le nom ega ly) o r ove rd is ten tion
(s to m ac h or u rin a ry b la dd e r)?
T h us , b y kn ow ing th e ge ne ra l d is -
tr ibu tion o f n eo na ta l a bd om ina l
m a sse s , as w e ll as th e h is to ry an d
p hys ic a l fin d ing s , the ph ys ic ian c an
m a ke a m o re foc use d d iffe ren tia l d i-
a gn os is o r e ven a sp ec ific d ia gn os is
w itho u t ha v in g to o rde r se ve ra l co s tly
o r tim e -con su m in g h em a to lo g ic o r
im ag in g te s ts . F o r e xa m p le , a n ew -
bo rn in fa n t w ho is fou nd to hav e a
un ila te ra l, irreg u la r, c om press ib le
flank m a ss w itho u t e v ide nce o f g as-
tro in te s tin a l im pa irm e n t is like ly to
ha ve a m ulticys tic , dys p las tic k id ne y .
T hu s , fu rth e r e va lu a tion can b e d i-
rec te d to w ard th is ten ta tive d ia gn o-
s is . A ren a l u ltraso un d m ay b e the
o n ly s tu dy n ec ess a ry to c on firm th is
d iagnos is .
P h y s ica l fin d in g s can b e
u se fu l in n a rro w in g th e
d iffe ren tia l d iag no sis .
A fte r the h is to ry h as b ee n ob ta in ed
a nd p hy s ica l ex am ina tio n p e rfo rm ed ,
p la in ab do m in a l rad io g rap hs sh ou ld
b e o b ta in ed . C on s ide ra b le in fo rm a-
tion c an be o b ta ine d fro m th is s im p le ,
ine xpe ns ive tes t. T h e b ow e l ga s pa t-
te rn can in d ica te o bs tru c tio n o r d is -
p la cem en t w h ic h m ay be he lp fu l in
d e te rm in in g w h e the r th e m a ss is in -
tra - o r re tro pe riton ea l. C alc ifica tion
ca n su gg es t neu rob la s tom a, h ep a to -
b la s tom a, o r m eco n ium p erito n itis .
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b n o r
F ig 1 . D is tr ibu tio n o f ab dom ina l m a sse s in n eona te b y
o rgan sys tem . D a ta der iv ed from K irks
e t a l. R ad io l C lin N orth A m. 1981 ;19 :52 7 -54 5 .
A n ab d o m in a l rad io g ra p h an d
an u ltra so u n d m ay b e th e
o nly im ag in g tec h n iq ues
nec es s a ry .
N E O N A T O L O G Y
pediatr ics i n r ev ie w #{149} vo l. 11 n o . 6 d ec em b er 19 89 P IR 173
If the re a re n o c lin ica l o r ra d io -
g ra ph ic find in gs sug ge s tiv e o f a
b ow e l ob s tru c tion , th en ab do m in a l u l-
tra so und is the ne x t ap p rop ria te
s tu dy . A bd om in a l u ltraso un d has
p rove d to be a va lu ab le d ia gn os tic
to o l w h ic h ha s th e a dd ed b ene fits o f
b e ing pa in le ss , h a rm les s , a nd in ex -
p en s iv e , re qu ires no se da tion , a nd
c an b e pe rfo rm ed a t th e be ds ide . F re -
q ue n tly , u ltra sou nd can pro v ide a de -
fin itiv e d iagn os is by d iffe re n tia tin g
so lid fro m c ys tic m as ses a nd d e fin in g
th e o rga n o f o rig in . R e la tive d is ad -
v an ta ge s in c lu de a g rea te r de pen d-
e nc e o n the u ltras on og ra ph er fo r
in te rp re ta tion , th e ina b ility o f u ltra -
so un d to sca n th rou gh bo ne or gas ,
a nd its lac k o f ab ility to p rov id e in fo r-
m atio n ab ou t o rgan fun c tio n .
C om p u te d to m og raph y (C T ) is cu r-
ren tly th e m os t ve rsa tile im a g ing p ro -
c ed u re fo r th e ev a lua tion o f a bd om i-
n a l m ass es . It ha s th e a dv an ta ge o f
p rov id in g p rec ise an a to m ic d e ta il, es -
pe c ia lly fo r the e va lua tio n o f s o lid tu -
m ors o f the re tro pe riton eu m (e g , m e-
so blas tic ne ph ro ma, neu rob la stom a,
sa croco ccy ge a l te ra to m a) a nd the
pe riton ea l cav ity (eg , he pa to b las -
to m a , o va rian te ra tom a). It ha s the
d isa dva n tag es o f re qu ir ing m od era te
do ses o f ion iz ing ra d ia tio n a nd is ex -
p ens iv e . In ad d itio n , to ob ta in an o p-
tim a l C T sca n , sed a tion is n ea rly a l-
w a ys re qu ire d fo r the ne on a te .
M ag ne tic res ona nc e im ag ing (M RI)
is a re la tiv e ly n ew m od a lity tha t ca n
b e u sed in th e e va lua tio n o f n eo na ta l
a bd om in a l m asse s . Its true po te n tia l
h as no t y e t b ee n fu lly re a liz ed . It ha s
th e ad va n tag es o f av o id ing ion iz in g
ra d ia tio n a nd in trav en ou s o r e n te ra l
c on tra s t a re n o t ne ces sa ry . M R I ca n
p rov ide a na to m ic d e fin ition in se ve ra l
d iffe ren t p lan es . B eca us e a m as s ca n
b e v ie w ed in se ve ra l d iffe ren t p lan es ,
a m ore spe c ific a na tom ic lo ca tion ca n
b e de te rm ined . D iffe re n tia tio n o f b e -
n ig n from m a lig na n t so lid tu m ors m ay
b e po ss ib le w ith th is te ch no lo gy ,
b ase d on d iffe ren t ce ll c ha ra c te ris -
tics . M RI ha s b ee n u sed fo r de tec tion
o f th rom b us a nd tum o r in the re na l
ve in a nd in fe rio r v ena c ava . It m ay b e
u se fu l in de te c tin g fe ta l ab do m ina l
an om a lies a s its us e in p re gna nc y
b eco m es m ore w ides p re ad . T h e d is -
adv an ta ge s o f M R I a t the p rese n t
tim e are its m ore lim ite d ava ilab ility ,
con s ide ra b le e xp en se , a nd ne ed fo r
sed a tion to ke ep the p a tie n t re la tive ly
m otio n les s du ring th e s tud y .
O n e o r m ore o f th e p re v ious ly de -
scribed im ag ing m oda litie s , a lth ou gh
no t d irec te d a t a sp ec ific o rg an , m ay
prov id e a sp ec ific d iag no s is a nd e lim -
m a te the ne ed fo r fu rth e r s tu d ies .
H o w eve r, s eve ra l o the r tes ts a re
av a ila b le to s tud y th e a na tom y o r
fun c tio n o f s pec ific o rg an s .
R ad io nu c lid e s can s o f sp ec ific o r-
ga ns hav e prov ed to be use fu l in
ev a lua ting c e rta in n eo na ta l ab do m i-
na l m a sse s . R a d ia tion e xp osu re can
be m in im ize d by ad m in is te rin g the
m in im um am oun t o f rad iop ha rm ac eu -
tic a l age n t re qu ire d to o b ta in a re lia -
b le exa m ina tion . A re na l s can us in g
tech ne tiu m 99 m -Ia be le d d ie thy le ne -
tr ia m in e a llo w s p re c ise a sse ss m en t
o f ren a l fu nc tion a nd the re la tive co n -
tr ib u tio n p rov id ed by ea ch k id ney . B il-
ia ry ex cre tion ca n be a sse sse d by
tech ne tiu m 99 m -la be le d de riv a tiv es
o f im ino d iace tic a c id in sus pe c ted
ca se s o f e x trahe pa tic b ilia ry tra c t
an om a lie s (e g , c ho le do cha l cys t). A
live r-sp lee n sca n w ith te ch ne tium
99 m -Iab e led s u lfu r co llo id m ay b e
us e fu l in d ia gn os in g liv e r tum o rs o r
sp le n ic e n la rge m en t bu t p ro ba b ly o f-
fe rs litt le m ore in fo rm a tion th an C T .
V o id ing c ys to u re th ro g ra ph y is th e
o p tim a l m etho d o f as ses s ing ve s ico -
u re te ra l re flu x an d the u re th ra l an a t-
o m y in b oys . H yd ro ne ph ro s is a nd hy -
d rou re te r s ec ond ary to re flu x , an ab -
n o rm a lly inn e rva te d b lad de r, o r
po s te rio r u re th ra l v a lves a re b es t
eva lu a te d by vo id ing cys to u re th ro -
g raphy .
In tra ve nou s p ye lo g rap hy , a t on e
tim e th e on ly m e tho d o f e va lu a tin g
re na l an a tom y a nd fun c tio n , h as be en
c ircu m ve n ted by th e ava ilab ility o f u l-
traso un d , C T, and re na l s c in tig ra ph y .
B eca us e th e ne w bo rn in fan ts k idn ey s
a re im ma tu re , in tra ve no us py e log ra -
ph y h as p ro ve n in ade qu a te . T o ob -
ta in a m ore a ccu ra te s tud y , it is ne c-
e ssa ry to w a it 1 to 2 w ee ks a fte r
b irth , a t w h ich tim e be tte r de fin itio n
o f th e re na l co llec ting sys te m and
ure te rs can b e o b ta ine d .
O th e r m od a lities , suc h as a ng io g -
rap hy a nd ve no gra ph y , h av e a lim ited
ro le in the ev a lua tion o f n eo na ta l a b -
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A bdo mina l M asse s
P IR 1 7 4 p e d ia tric s in re v ie w
#{149}
v o l. 1 1 n o . 6 d e c e m b e r 19 8 9
d om in a l m a sse s . F o r e xam p le , a n -
g iog ra ph y m ay be in d ica te d fo r p a -
tien ts w ith a he pa tic tum o r in w hom
a sse ssm en t o f res ec ta b ility is b e ing
de t e rm ined .
W OR K U P B Y A N A T O M IC
L O C A T I O N
Ret roper i toneal M a s s e s
A n a lg o rith m h as be en de v ised (F ig
2 ) to a id in the ev a lua tion o f a ne o-
na ta l ab do m in a l m a ss . T h is ha s b een
m ad e as s im p le as p oss ib le . A m o re
co m pre hen s ive d is cu ss ion fo llow s.
Kidney.
S in ce the m a jo rity o f ne o -
na ta l ab do m in a l m as se s a re re na l in
o rig in , the flan k is th e m os t com m on
s ite o f p re sen ta tio n . A lis t o f p oss ib le
m a sse s a ris ing from th e k id ne y o r
ad re na l g la nd can be fou nd in T a b le
1
.
D e fin in g the m a ss as e ith e r s o lid
o r cy s tic d u ring p hy s ica l e xam in a tio n
and u ltraso un d is us e fu l in na rrow in g
th e d iffe ren tia l d iag no s is . C ys tic
m a sse s a re m o re co m m o n, w ith m u l-
ticys tic , d ysp la s tic k idn ey , a nd hy d ro -
n ep hros is m ak ing up m o st o f the ne o-
n a ta l fla nk m ass es an d ac cou n ting
fo r 4 0% o f a ll n eo na ta l a bd om ina l
m asse s . A m ultic ys tic , dy sp la s tic k id -
n ey co ns is ts o f m ultip le no nc om mu n-
ica ting c ys ts th ou gh t to be th e res u lt
o f a tre s ia o f the u re te rop e lv lc sy s tem
a nd is o fte n p a lpa b le as a n irre gu la r
fee lin g , co m pre ss ib le flan k m ass . T h e
u ltra so und fin d ing s o f m ultip le h yp o -
e ch o ic , no nc om m u n ica ting c ys ts o f
va ria b le s ize s a re usu a lly d ia gn os tic .
B o th k id ne ys sh ou ld b e e va lua ted be -
ca us e in on e th ird o f ca se s the co n -
tra la te ra l k idn ey is a bn orm a l. M u lti-
cy s tic , dys p las tic k idn ey s a re n on -
fun c tio na l, an d the re fo re , it is
ge ne ra lly rec om m e nd ed tha t the y be
rem o ved to avo id de ve lo pm e n t o f h y-
pe rte ns ion , in fec tion , o r ca rc ino ma .
In fan ts w ith c on ge n ita l h yd ro ne -
ph ro s is a re us ua lly as ym pto m atic ;
the flan k m a ss res u lts from m e ch an -
ic a l ob s tru c tio n , d e fec ts in u re te ra l
p rop u ls ion se con da ry to m us c le d ys-
fun c tio n , o r ve s ic ou re te ra l re flux . U re -
te rop e lv ic ju nc tion ob s truc tion is th e
m ost co m m on c au se o f h yd ro ne -
p h ro s is (2 2% ) a nd is c ons id e re d to
b e d ue to in tr in s ic o r e x tr in s ic m e -
c ha n ica l o bs tru c tio n o r po o r p e ris ta l-
s is o f th e p ro x im a l u re te r. P os te rio r
u re th ra l v a lves , u re te rov es ica l ju nc-
tio n ob s truc tion , a nd e c top ic u re te ro -
ce le s a re o the r ca us es o f hyd ron e -
ph ro s is bu t, u n like u re te ro pe lv ic ju nc-
tio n o bs truc tion , a re ass oc ia te d w ith
u re te ra l d ila tio n (h y d ro ure te r) ,
a fin d-
ing frequ en tly de te c tab le by u ltra -
s o u n d . R e flu x
m a y o ccu r a lo ne o r in
a sso c ia tio n w ith pos te rio r u re th ra l
va lve s . T he in itia l w o rk up fo r hy d ro -
n ep hros is sh ou ld be w ith u ltra sou nd
a nd v o id ing c ys tou re th ro g rap hy .
U s ing the se s tu d ies , o ne w ill b e ab le
to de te rm in e the leve l o f ob s tru c tio n
a nd w he th e r u re te rov es ica l re flux is
p re se n t. N o fu rth e r im a g ing p ro ce -
d u res m ay b e ind ic a ted , d ep en d ing
o n th e re su lts o f th ese s tu d ies . R en a l
sc in tig ra ph y to eva lu a te re na l fu nc-
tio n a nd in trave no us p ye log rap hy (1
to 2 w ee ks p os tn a ta lly ) to b e tte r de -
fin e th e a na tom y m a y be u se fu l un de r
sp ec ific c ircu m stan ce s . C T an d M R I
a re n o t
ne ces sa ry . O b stru c ting le -
s ion s in vo lv in g th e u re te ro pe lv ic ju nc -
tio n o r u re te rov es ica l jun c tio n a re
trea te d su rg ica lly . T em p ora ry de -
co m pre ss ion b y u ltra so un d-gu id ed
pe rcu tan eo us ne ph ros tom y ca n b e
us e fu l in p re se rv in g ren a l fu nc tion
an d as ses s ing w he th e r ren a l fu nc tion
m ig h t im pro ve in a sev e re ly com pro -
m is ed k idn ey . T h is w ou ld p ro v ide in -
fo rm a tio n c on ce rn in g w h e the r to re -
pa ir o r res ec t th e inv o lved k id ne y .
R e flux sev e re en oug h to p rod uce s ig -
n ifica n t h yd ro ne ph ro s is is us ua lly the
resu lt o f u re th ra l o bs truc tion (po s te -
rio r u re th ra l va lves ) o r a ne uro ge n ic
b la dd e r. V es ic os to m y h as p rov ed to
b e h e lp fu l as in itia l trea tm en t. T ra ns -
u re th ra l fu lg u ra tion is the de fin itive
tre a tm e n t fo r p os te rio r u re th ra l
va lves .
T h e k id n ey a cc o u n ts fo r
m ore th an 5 0 o f n eo nata l
ab do min al m asse s .
In te rm itten t c a the te riz a tio n ha s
be en u se d w ith s om e suc ce ss in pa -
tie n ts w ith ne u rog en ic b la dd e r.
P olyc ys tic k id ney d ise as e is usu a lly
b ila te ra l, ha s a ge ne tic b as is , an d re -
qu ire s no spe c ific tre a tm e n t. T h e in -
fan tile fo rm is u n ifo rm ly fa ta l. T he
ad u lt fo rm ra re ly occ u rs in the n eo -
na te and o n ly req u ires su rv e illan ce
fo r th e d ev e lop m en t o f hy pe rte ns ion
a nd re na l fa ilu re .
S o lid re na l le s ion s occ u r m uch le ss
fre qu en tly th an cys tic les io ns . M ost
o f th ese m a sse s a re b en ig n a nd in -
d ud e ren a l ve in th rom b os is a nd m e -
so b las tic nep hro m a. R en a l v e in
th rom b os is in th e ne w b orn u sua lly
p ro du ce s n o sym p to m s an d m a y be
a sso c ia ted w ith he m atu ria o r p ro te in -
u ria . In ad dition , th ro mb ocy to pe nia
a nd /o r d is sem in a ted in tra vas cu la r
co ag u la tion m a y be in itia l s ig ns . D e-
hy d ra tion an d h em ocon ce n tra tio n a re
us ua lly p re d ispo s ing fa c to rs . In fan ts
o f d iab e tic m o th e rs a re pa rticu la rly
su sce p tib le . D iag no s is is u sua lly p os-
s ib le w ith u ltras ou nd a lon e , w h ich
sh ow s a bs en ce o f b lo od flow in the
ren a l v e in a nd a n en la rg ed k idn ey . C T
or M R I c an de m on stra te th ro m bu s in
the ren a l ve in a nd /o r in fe rio r v ena
ca va . A d ie thy len e tria m ine re na l sca n
ha s b ee n sug ge s ted a s an o th e r
m e tho d o f d iag no s ing re na l ve in
th rom bos is . H ow e ver, the se p roc e -
du re s a re u su a lly n o t n ece ssa ry .
T re a tm en t is n on op era tive an d co n-
s is ts o f re hyd ra tio n an d co rre c tio n o f
e lec tro ly te d is tu rba nc es . H ep arin iza -
tion is on ly in d ica te d in c ase s o f pu l-
m o na ry e m bo lu s (ra re ). R ec ove ry o f
re na l fun c tio n is va ria b le bu t m a y b e
g o o d .
M eso b las tic ne ph ro m a (fe ta l ren a l
h am a rto m a) is b en ig n an d the m o st
c om m o n ne on a ta l re na l tum o r. M o re
tha n 9 0% of th es e tum ors a re p a l-
p ab le an d 1 8 % o f the in fan ts h av e
h em a tu ria . U ltras ou nd is u su a lly d i-
a gno s tic , b u t a C T sc an m ay b e h e lp -
fu l in o lde r ne on a tes . C om p le te s u r-
g ica l e xc is ion is cu ra tiv e fo r m e so b-
la stic n ep hrom as, bu t d iffe ren tia tion
from W ilm s tu m or ca n o n ly be do ne
a fte r su rg ic a l rem ova l an d h is to lo g ic
e xam ina tio n. N ep hrob las tom atos is
an d n od u la r ren a l b las te m a are ra re
b ila te ra l les ion s in w hic h bo th k id ne ys
ha ve m ultip le con flu en t n od u les co rn -
p os ed o f m e ta ne ph ric e p ithe liu rn . U l-
tra so un d a nd C T are the o p tim a l
m etho ds o f d ia gn os is .
N eon a ta l W ilrns tum o r (ne ph ro -
b la s tom a ) is ra re . E va lua tio n is usu -
a lly by u ltra sou nd a nd C T. It is d iffic u lt
to p re op era tive ly d iffe re ntia te m esob -
las tic n ep hro m a from W ilrns tum o r.
S u rg ic a l e xc is ion is the trea tm e n t o f
c ho ice fo r bo th les io ns .
Ad rena l G land . T he ad ren a l g la nd
m ay be the so urce o f a fla nk m as s in
th e ne w bo rn . T h e m o st co m m on
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A b ia ts :
C T , com pu ted to m og raph y; M R I, m a gne tic reso nan ce im ag ing .
A b d o m in a l M as s es
P IR 1 7 6 p e d ia tric s in re v ie w # { 1 4 9 }v o l. 1 1 n o . 6 d e c e m b e r 1 9 8 9
T A B L E 1 . N e o n a ta l F la n k M a s s e s A fte r U ltra s o n o g ra p h ic C a te g o n za tio n *
U a :d
R e la tive In c id e nce A sso c ia te d F ind in gs
F urth er M an ag em en t
Re n a l
Cyst i c
Hyd ronephros is
C om m o n M ay be b ila te ra l V o id ing cysto u re th rog ra m , re na l
s c a n, d e c om p r es s io n /r ec o n -
s t ruc t ion
M u ltic ys tic k id ne y (typ e C o m m o n U re te ra l a tre s ia m ay be b i- V o id in g cys to u re th rog ra m , re n a l
II) la te ra l scan , ne phre cto m y
In fa n tile po lycys tic k id - U ncom m on B ila te ra l p u lm ona ry h ypo - S upp ortive re sp ira to ry
care
a nd d i-
n ey d isease (type I)
p la s ia , h epa tic d ise ase a lys is , excre to ry u rog ra m if
n e e d e d f or d ia gn os is
A du lt po lycystic k idney R are in neo na te s B ila te ra l la rge re na l cys ts F o llo w -u p fo r de ve lopm en t o f hy-
d ise ase (type III)
p erte ns io n, re na l fa ilu re
Sol id
R e na l ve in th ro m bo s is U ncom m on
B irth trau m a, m ate rn a l tox -
em ia o r d iabe tes m ellitus
H yd ra tion , ac id -b ase , an d e le ctro -
ly te co rrec t ion ; C T scan or M R I
if u ltra so un d n on dia gn os tic
M esob lastic nep hrom a U ncom m on O ccas ion a l h ype rtens ion C h est roe n tg enog ram , C T sca n ,
o r M R I; n ep hre cto my
W ilm s tum o r R are in n eo na tes M ay b e b ila te ra l hype rte n -
s io n, h em a tu na
C he st an d ab dom ina l C T , rad ica l
nep h rec tom y, m ay requ ire ad ju -
R a r e
B ila te ra l re n a l e n la rge m en t
w ith s o lid p a ren ch ym al
densit ies
van t the ra py
P o ss ib le b iop sy , co n tinu ed fo llo w -
up
Nephrob las tomatos is
Adrena l
Cyst i c
E a rly he m o rrh age U ncom m on B irth trau m a, a nem ia , sh ock R u le ou t on go in g hem orrha ge ,
eva lua te fo r c ava l c om pres sio n,
se r ia l u ltra sou n d to d o cum en t
sh r inkage
Sol id
L a te he m orrh age U nco m m on A dre na l insu ffic iency, ca lc i-
f led r im a rou n d he m a -
t o m a
S eria l u ltrasoun d to ru le ou t en -
la rgemen t a s in n eu ro bla sto m a
N e urob las tom a Iso la ted m a ss o r w ith
m eta stic d is ea se
(s tag e IV -S )
Invo lvem en t o f sk in , live r,
b one m arrow ; o cca siona l
hype r tens ion
U rina ry va n illy lm an de lic an d h om o-
van ill ic ac ids , tum or re se ction o r
b iopsy
m a sses inc lud e a dren a l he m o rrh age
an d ne urob las tom a. B irth trau m a,
an em ia , o r ev id ence o f ad ren a l insu f-
f ic iency m ay be pre sen t in th e n eo-
na te w ith ad rena l hem orrha ge . H o w -
eve r, the usua l find ing is a pa lpab le
m a ss . In 7 0% of p a tien ts , the hem -
o rrh ag e oc cu rs in the righ t ad re na l
g land . D ia gno s is is usua lly b y u ltra -
so und a nd no spe c ific tre a tm en t is
requ ired . H ow ever, if b ila te ra l hem -
o rrh age (5% to 1 0% ) is p re se n t, s te -
ro id re p lacem en t m ay be necessa ry .
N eu rob las tom a in the ne ona te fre -
q uen tly a rises in the ad rena l g land o r
sym p a th e tic cha in . S tipp led ca lc ifica -
t ion in the m ass v isua lize d b y ab do m -
in a l ra d iog raph c an h e lp m ake the
d ia gn os is . U rina ry ca te ch o lam ine s
a nd m etab olites (e g, va nilly lm an de lic
a c id and h om o va n illic a c id ) sho u ld be
m easured . U ltrasoun d sh ow s a ho-
m o ge ne ou s ec ho ge n ic so lid m ass
fre que n tly assoc ia ted w ith s t ipp led
c a lc ifica tion . C o ng en ita l neu ro -
b las tom a o fte n is a ssoc ia ted w ith
sk in , live r, and bo ne m arro w m etas -
tase s (s ta ge IV -S ). T he re fo re , these
po ten tia l m e tas ta tic s ites sh ou ld be
in ve stig a te d . C T can b e use fu l in eva l-
ua tin g the s ite o f o rig in as w e ll as
a re as o f in traa bdo m in a l ex tens io n o r
m e tas tases . T rea tm e n t d epe nds on
the sta ge . S u rg ica l exc is ion o f th e
p rim ary tum or in s tage s I, II, and IV -
S is th e usua l tre a tm en t. R a d ia t ion
a nd che m o th e ra py a re im p ortan t ad -
ju van t m odes o f tre a tm en t.
O the r R e trope rito nea l M asses .
O th er tum o rs , bo th c ys tic a nd so lid ,
m a y arise in th e re tro pe riton eum .
C ys tic le s ion s us ua lly a re lym pha ng i-
o m as . S o lid m ass es m a y b e te ra to -
m a s or s o ft tiss ue tum o rs suc h as
rha bd om y osa rco m a. U ltraso un d a nd
C T a re u se fu l m e thod s o f d iag nos is .
M R I m ay prove to be m o re use fu l
th an C T w he n e va lua tin g th ese le -
s ion s . T re a tm e n t is b y su rg ic a l e xc i-
s ion.
In trap er ito ne al M ass es
R igh t U ppe r A bdom ina l (H epa tob il-
ia ry) M asse s. M ost righ t up pe r qu ad -
ran t m ass es a re h ep a tob ilia ry in o n -
g in . C ys tic m as ses in th is loca tio n
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T A B L E 2 .
Re co m m e n d e d
O b ste tr ic M a n ag e m en t fo r
lJtrasound- ldenti f led
F e t a l
U ro b o g ic
Abnormal i t ies
T e rm g e sta tio n: V a gin a l d e liv ery
I nt es tin a l a tr e sia
M es en te ric , o me nta l o r sp le nic
cys ts
I n te s ti n a l d u p li ca t io n s
Ompha loce le
S m a l l to m o de ra te s ac ro co cc yg -
e a l t er at om a
O v aria n c ys t
T e rm
g es ta tio n : P o ss ib le c es ar ea n
de l ivery
G i an t o m p h a bo c el e
L arg e s ac ro co cc yg ea l te ra to m a
P oss ib le p re te rm g es ta tio n: V ag i-
n al o r ce sa re an d elive ry
Gast roschis is
* E xp erim en ta l a nd co ntro ve rs ia l.
N E O N A T O L O G Y
p e d ia tric s in re v ie w # { 1 4 9 }v o l. 1 1 n o . 6 d e c e m b e r 1 9 8 9 P IR 1 7 7
in c lud e hyd rop s o f the ga llb la dd e r,
ch o led och a l c ys t, a nd s o lita ry live r
cys ts . T h es e m as ses a re p a lpa b le
an d e ith e r ca us e n o sym p tom s o r
cau se jau nd ic e (ch o led oc ha l cy s t).
S o lid m as se s inc lud e h ep a tic he m an -
g ioe nd o the lio m a, cav e rn ous hem an -
g iom a, h am artom a, a nd he pa to b las-
tom a . T he find in gs d ep en d on the
speci f ic les io n . G ene ra lize d h ep a to -
m e ga ly o r a m ass c on tigu ou s w ith
th e live r b y ph ys ica l exa m ina tion a re
b es t eva lu a te d by u ltraso un d an d C T
with in trave no us c on tra s t. C ys tic
m a sse s in the righ t u pp er qu ad ran t
a re b es t e va lu a ted b y u ltra so und an d
rad io nu c lid e sc ann in g . If a ch o led o -
c ha l cy s t is iden tified , the n re sec tio n
w ith R ou x-e n-Y h ep atic oje ju no sto m y
sh ou ld b e pe rfo rm ed .
T h e in itia l s ign s o f a he pa tic cay -
e rno us he m an g iom a or he m ang ioe n -
d o the lio m a m a y be ind ica ted by a
m ass , b y ge ne ra liz ed he pa to m eg a ly ,
a nd /o r by co ng es tive he art fa ilu re .
D ia gn os is is by C T o r live r sc an w h ich
sh ow s a h ig h ly v as cu la r le s ion . M R I
m a y prov e to be a b e tte r im ag in g
m od a lity . B o th va scu la r les io ns m a y
sp on ta ne ou s ly in vo lu te . S te ro id the n -
ap y m ay oc cas io na lly ha s ten th is
p roc ess . H o w eve r, con ge s tiv e h ea rt
fa ilu re m ay be pro fo un d an d re qu ire
in te rven tio n b y h ep a tic a rte ry e m bo -
liza tio n, lig atio n, o r re se ctio n.
H e pa tic ham artom a is a firm m as s
th a t is h om o ge neo us by u ltras ou nd
o r C T . T rea tm e n t is by su rg ic a l e xc i-
s ion . H e pa tob la s tom a is a m a lig na n t
tu m or th a t m ay be ide n tified in a n
in fan t w ith m ass ive he pa to rne ga ly o r
a sp ec ific m ass . It is ass oc ia te d w ith
a n e le va te d se rum a -fe to p ro te in
leve l. C T an d pe rh ap s M R I a re th e
o p tim a l im a g ing tec hn iq ue s . A rte n i-
o g rap hy m a y b e ind ic a ted to de te r-
m in e rese c tab ility . S urg ica l e xc is ion
is the tre a tm en t o f c ho ic e . H ow e ver,
so m e les io ns th a t a re in itia lly un re -
se c tab le m a y b e a m en ab le to ex c i-
s io n a fte r a c ou rs e o f ch em othe ra py .
Gastro in te s tina l M asses . M as s es
re la te d to the ga s tro in tes tina l trac t
c an be d e te c ted in a n in fa n t by th e
p hys ica l find in gs o f a pa lpab le m a ss ,
g en era lized a bd om ina l d is te n tio n , o r
in tes tina l ob s truc tion . A pa lp ab le a b -
d om ina l m a ss a sso c ia ted w ith in tes -
tina l ob s truc tion a lm ost a lw ays o rig i-
n a tes in th e ga s tro in tes tina l trac t. In
th e ab se nce o f in te stina l ob struc tion ,
a m ass a sso c ia ted w ith the ga s tro in -
tes tina l tra c t m ay take sev e ra l da ys
o r w ee ks to b e id en tifie d . W h en pa l-
p a te d , m ost ga s tro in tes tina l trac t-re -
la te d m ass es a re s m oo th , ro un d , a nd
m ob i l e .
E va lu a tio n o f an in tra pe n iton ea l
m a ss s usp ec te d o f be in g re la ted to
the ga s tro in tes tin a l trac t sho u ld be g in
w ith an ab do m in a l roen tge no grap h .
T h is m a y s ho w pa rtia l in tes tina l ob -
s truc tion a nd /o r linea r ca lc ific a tion in
the w a ll o f a cy s t. F u rthe r ev a lua tion
sh ou ld b e ac co m p lis he d by u ltra -
sou nd . G a stro in te s tin a l con tra s t
s tud ie s (up pe r ga s tro in te s tin a l o r ba r-
iu m e ne m a) m ay b e ind ic a ted , de -
pe nd in g o n the find in gs o f the o th e r
s tudies .
D up lica tio ns a re th e m o st c om m o n
ga stro in tes tin a l m a sse s in the ne o-
na te . T he y c an o ccu r from th e s to m -
ac h to the rec tu m , bu t th e ileo ce ca l
a re a is th e m os t co m m o n s ite . D up li-
ca tion s a re u sua lly cys tic an d d o no t
co m m un ica te w ith the no rm a l g as-
tro in tes tina l lum e n . H ow ev er, so m e
du p lic a tions a re tu bu la r, c om m un i-
ca te w ith th e ad ja ce n t b ow e l lu m en ,
an d co n ta in ec to p ic ga s tr ic m uc osa .
B o th fo rm s can be d e tec te d a s a
m as s o r in tes tina l o bs truc tio n (u su ally
pa rtia l). T he la tte r v a rie ty can ca us e
bleeding s im ila r to a M e cke l’s d ive r-
ticu lu m , b u t th is us ua lly d oe s n o t o c-
cu r in th e n eo na ta l pe riod . C ys ts o n ig -
m a ting in th e o m en tum o r m e sen te ry
a lso oc cu r. In u te ro in tes tina l pe rfo -
ra tio n ca n prod uc e a m e co n ium c ys t
w h ich o fte n h as a rea s o f ca lc ifica tio n
( “mecon ium p erito n itis ”) th a t a re v is i-
b le o n ab do m in a l ra d iog ra ph s . A
sp len ic cy s t m a y ra re ly b e p res en t in
th e n ew b orn .
D ila ted in te s tin a l loop s fro m in tra -
lu rn ina l a ir o r in te s tin a l co n te n ts ca n
b e m is take n fo r an in trap en ito nea l
m ass . T he w o rk up sho u ld be g in w ith
p la in ab do m in a l rad io g ra ph s to ru le
ou t o bs truc tion . If obs tru c tio n is p res-
en t, in tes tina l a tres ia (s ), m ec on iu m
ileus (cy s tic fib ros is ), vo lvu lu s o r
H irs chs p ru ng d is ea se a re p oss ib ili-
ties . A C T s can or M R I a re un ne ce s-
s a ry s tud ie s b ec au se th ey d o n o t p ro -
v id e u se fu l in fo rm atio n re la te d to ga s-
tro in te stin al m asse s o r obs tru ctio n.
P elv ic M asse s
T h e find in g o f a m as s a ris in g fro m
th e pe lv is in bo ys is like ly to be a
d is ten de d b la dd er o r u ra ch a l rem -
n an t. In g ir ls , hy d rom etroco lp os an d
ova ria n cy s ts a re a dd itio na l d ia gn os -
tic p oss ib ilit ies . M asse s th at o rig in ate
fro m the p resa cra l s pa ce in c lud e sac -
ro co ccyg ea l te ra to m a a nd an te rio r
m en in go m ye loc e le . T he p hys ic a l e x-
a m ina tion b y a bd om ina l p a lpa tio n ,
re c ta l exa m ina tion , an d in sp ec tion o f
th e in tro itu s in g ir ls ca n be he lp fu l in
a rriv in g a t a te n ta tiv e d iag no s is .
E x am ina tio n o f th e in tro itus in a g ir l
m igh t re vea l a b u lg ing m e m bra ne in
c as es o f im pe rfo ra te h ym e n o r a p in -
p o in t o pe n ing in the pe rin eu m as so -
c ia ted w ith va g ina l a tres ia . A n u ltra -
s oun d w ill co n firm e ith e r a d ila ted
v ag in a (hyd roco lp os ) o r d ila te d va -
g in a a nd u te ru s (h yd ro me tro co lp os).
T re a tm en t is su rg ica l an d d ep en ds on
th e sp ec ific p ro blem .
A ltho ug h the ova ry is a pe lv ic
s tru c tu re , ov a rian les io ns in ne w bo rn
g ir ls e x ten d ou t o f the pe lv is a s the y
g row a nd m o st o fte n a re d e te c ted as
a n a bd om ina l m ass . In fac t, a cy s tic
m a ss th a t ap pe ars to b e m o b ile
w ith in a fem a le n ew b orn ’s lo w e r ab -
d om e n is m ost lik e ly to b e ov a ria n in
o rig in . U ltras oun d w ill c on firm the
c ys tic na tu re o f th e m a ss bu t m a y
no t be a b le to d e fin e the o rg an o r
o rig in . If th e cy s t p rod uce s n o sym p -
tom s, it m ay be po ss ib le to fo llow -u p
the in fa n t by se ria l u ltra sou nd s b e-
ca use som e ov arian cys ts w ill s pon -
tan eo us ly res o lve . If su rg e ry is w ar-
ran te d , th e g oa l sho u ld be res ec tion
-
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P la n n in g fo r p ro m p t an d
appr opr ia te
postna ta l
tre a tm e n t is th e ad va n ta g e o f
p ren ata l d ia g n o s is o f a n
a b d o m in a l m as s .
T A B L E 3 . M an ag em en t o f G en ito urina ry A no ma lie s D ia gn os ed in U te ro
* A b b re v ia tio n s : U P J, u re te ro p e lv ic ju n c tio n ; U V J,
u re te ro ve s ica l junc tion ; V CU G, v o id i ng c y s to u r e th r o g ra m .
t E xp erim en ta l a nd con tro ve rs ia l (s ee tex t
fo r
discuss ion) .
A bd om in al M asse s
P IR 1 7 8 p e d ia tric s in re v ie w #{149} v o l. 1 1 n o . 6 d e c e m b e r 1 9 8 9
o f the cy s t a lo ne , s pa ring as m u ch
ov a ria n tiss ue a s po ss ib le . S o lid le -
s ion s o f th e o va ry a re u sua lly te ra to -
m as . T rea tm en t is b y e xc is ion o f th e
m as s o r ov a ry if n ec ess a ry to ru le ou t
m a l i gnanc y .
S a croc occ yge a l te ra tom as are the
m o st c om m o n co ng en ita l ne op la sm .
T he d ia gn os is is u su a lly ob v iou s , be -
c aus e the y typ ica lly a re e xop hy tic
m a sse s p os te rio r to the s ac ru m . O c-
c as ion a lly , the y m ay g row prim arily
p re sa cra lly a nd e x ten d ou t o f the p e l-
v is an d be d e tec te d a s a m a ss du rin g
a re c ta l o r a bdo m ina l e xa m in a tion .
U ltraso un d usu a lly re vea ls so lid a nd
c ys tic co m p one n ts . A C T sc an w ith
c on tra s t w ill h e lp d e fine the loca l ex -
ten t o f th e tu m o r an d its re la tio nsh ip
to su rrou nd in g s tru c tu re s . A lthou gh
the g rea t m ajo rity o f sa cro coc cyg ea l
te ra to m a s a re b en ig n a t b irth , p ro m pt
e n b lo c rem o va l o f the tum o r a nd the
tip o f th e c oc cyx is ind ic a ted b ec aus e
p ro lon ged d e lay incre ase s the risk o f
a dve rse a ffe c ts fro m m a lig na nc y . A n -
te rio r m y e lom e n ing oc e le m a y, oc ca -
s io na lly , b e de te c ted a s a pe lv ic
m a ss , bu t the p re se nce o f low e r e x-
trem ity pa ra p leg ia a nd m usc le a tro -
p hy ge ne ra lly m a ke s th e d iag no s is
obv ious .
P R E N A T A L D IA G NO SIS
T h e in crea s ing u se o f fe ta l u ltra -
so no gra ph y h as p ro v ide d a u n iqu e
o pp ortun ity to p ren a ta lly d ia gn ose
a bd om ina l m ass es . F re qu en tly , th e
ne on a to log is t, p ed ia tr ic ian , a nd pe d i-
a tn ic s u rge on are con su lted b y th e
o bs te tr ic ian to re nd er ad v ice re ga rd -
in g the op tim al p en in a ta l c a re .
P re na ta l m an ag em e n t o f fe ta l in -
tra ab do m in a l a no m a lie s a re la rg e ly
ob s te tr ic in na tu re a t the p re se n t
tim e . T he y in c lu de the ne ed fo r m a -
te rna l tra nsp o rt to a fac ility in w h ich
op tim a l ne on a ta l an d pe d ia tr ic su r-
g ica l ca re a re a va ila ble , d ete rm in atio n
o f th e ty pe o f de live ry (c esa rea n o r
vag in a l), an d w h e th e r p rem atu re d e -
live ry is a pp ro p ria te . If res ou rc es fo r
in u te ro in te rven tio n a re a va ilab le , th is
m ay b e a c on s ide ra tio n . T he su g-
gested o bs te tr ic m an ag em e n t fo r
no ng en itou n ina ry fe ta l a no m a lie s d i-
ag no sed b y p re na ta l u ltra so un d are
sho w n in T a b le 2 . E le c tive ce sa re an
sec tion c an b e con s ide re d w h en
tho se a bd om ina l ab no rm a lities s uch
as g ian t om p ha lo ce le m igh t p ro du ce
dy s toc ia du rin g v ag in a l d e liv e ry . P re -
te rm d e liv e ry h as b ee n su gg es te d in
ca se s o f ga s trosc h is is b eca us e o f a n
in crea se d risk to th e ex trac oe lo m ic
in te s tin a l trac t la te in th e th ird tr im es-
ten . T he e tio lo gy o f th is is no t c lea r
bu t m a y be d ue to c on tra c tio n o f the
ab do m ina l w a ll o pen in g a nd s eco nd -
a ry vas cu la r co m pro m is e to th e in te s-
tin e . T h is c on cep t is no t p ro ve n , a nd
the re fo re , p re te rm de live ry is the se
ca se s re ma in s co ntro ve rs ia l.
G e n itou n ina ry an om a lies p re sen t a
g re a te r num be r o f m ana ge m en t op -
tions (T a b le 3 ). P a tien ts w ith u n ila t-
e ra l re na l d ise ase a re b es t m an ag ed
a fte r te rm d e liv e ry . A de qu a te ren a l
fun c tio n in the un a ffec te d k idn ey
d oe s n o t w arran t the ris ks a sso c ia ted
w ith in u te ro m a n ipu la tion o r p rem a -
tun e de live ry . H ow ev er, s eve re b ila t-
e ra l o bs truc tive u rop a thy is fre -
q ue n tly a sso c ia ted w ith s ign ifican t
po s tna ta l m orb id ity du e to pu lm ona ry
hy po p las ia . S uc ces s fu l trea tm en t o f
D ia gn o s is C a us e P re na ta l M an a ge m e n t P os tn a ta l M a n ag em en t
R en al a ge ne sis
Fa i led deve lopmen t , a u to s o -
S e le c tiv e a b ortio n a n d
fam - S up portive
In fa n tile p o ly cy stic k id n ey
m al
rece ss ive ily cou nse ling
d isease
A d u lt po ly cys tic k idn ey d is - A u toso m al d om ina n t
O b se rv e fo r h yp e rte n sio n
eas e
Mul t icys t ic
k idney
Fa i led ureteropelvic
devel -
o p m e n t
D e liv e r a t t e rm R en a l sc an to a sse ss fun c-
t ion
(a ffe cte d v s n on af-
fec ted s id e ) , u n i la t e ra l ne -
p h re c to my
H yd ron ep hros is , u n ila te ra l U PJ ob s tru c tio n , u re te ro -
c ele , ( NJ o b stru ctio n, re -
f lux
D e liv e r a t te rm V C U G to ru le ou t re flu x ,
r ena l s can to a sse ss fu nc-
t io n , d e c o m p r e ss io n / re -
cons truc t ion /nephrec tomy
H yd ro ne ph ros is , b ila te ra l U P J ob s tru c tio n , po s te rio r
u re th ra l va lve s , u re te ro -
ce le s , P ru n e b e lly
s y n -
d ro me , n eu ro ge nic b la d-
d en , m eg au re te r s yn -
d r o m e
W e ek ly u ltra so un d: o lig oh y-
d ra m nio s o cc u rs
(>20
w k: a ss es s
fo r
v a lue o f in
u te ro de co mpre ss ion if
a va ilab le t; > 3 2 w k:
de -
l iv er p re te rm fo r de -
c o mp re s s io n t )
V C UG to ru le ou t re flu x ,
r e n a l sc an to a sse ss fu nc-
t io n , d e c o m p r e ss io n / re -
cons t ruc t ion/excretory
u ro g ra p h y w h e n 7-1
0 d
o ld to as ses s an atom y
M eg acy s tis syn d ro m e U re th ra l ob s truc tion , n eu ro -
g en ic b la dd er (m e nin go -
m y e loc e le )
N o o l ig o h y d ra m n i o s -d e -
liv er a t te rm
V C U G , d e co m p re s si on /r e -
cons t ruc t ion
-
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N E O N A T O L O G Y
pediatrics in r ev ie w
#{149}
v o l. 1 1 n o . 6 d e c e m b e r 1 98 9
P IR 1 7 9
fe ta l u rina ry tra c t ob s truc tion ha s
be en lim ite d by o ur ina b ility to s e lec t
th e a pp rop ria te fe tu s fo r in te rve ntion ,
ie , the fe tus w h o h as re na l a nd pu l-
m o n a r y dam ag e se ve re en ou gh to
p rec lud e su rv iv a l w itho ut in te rv en tion
b u t no t y e t so sev e re tha t da m ag e is
irreve rs ib le if th e u rina ry ob s truc tion
is re liev ed . P rom is ing m etho ds be in g
e va lu a ted fo r p red ic ting a g oo d fe ta l
o u tco m e a fte r in u te ro u rin a ry tra c t
d ec om press io n inc lud e son og rap h ic
a sse ssm e n t o f ren a l p an en chy m a an d
te m po ra ry ca the te riza tion o f th e fe ta l
b la dd er. F eta l b la dd er c ath ete riz atio n
a llow s m e as urem en t o f u rina ry o u t-
p u t a nd q ua n tita tio n o f fe ta l u rina ry
s od ium an d ch lo ride co nc en tra tion s,
o sm ola n ity , an d c re a tin ine c le a ra nce
us in g m a te rna l b loo d sa m p le s . P res-
e n tly , in u te ro u rin a ry trac t de -
c om p ress io n sh ou ld b e c on s ide re d
inv es tiga tion a l a nd sh ou ld on ly b e
c a rrie d o u t a t ce n te rs w ith s pec ia l
in te re s t an d ex pe rien ce in th is a rea .
P re te rm d e liv e ry is an op tion tha t a l-
low s ea rlie r d eco m pre ss ion o f th e o b-
structed
u rina ry trac t in h igh ly se le c-
tive c ase s . A s s ta ted b e fo re , o ne
m u st w e ig h the ris k o f in te rve n tion
a ga in s t the risk o f p re m atu rity .
P re lim in a ry re su lts su gg es t tha t the
n eo na te s m ost like ly to b en e fit from
pre te rm d e liv e ry a re th os e in w ho m
o lig ohy dn am n io s d ev e lop ed a fte r 32
w e eks ’ ge s ta tio n w h en th e risk o f
p re m atu rity is re la tiv e ly le ss .
In u te no in te rve n tio n w ill be com e a
m ore like ly a lte rna tive w h en the ris ks
to the fe tus ca n be m in im ize d an d
in itia tion o f la bo r ca n b e a vo id ed fo l-
lo win g u te rin e m an ip ula tio n.
C O N C L U S I O N
M ost ne on a ta l ab do m in a l m a sse s
a re b en ig n a nd m ore th an ha lf a re o f
re na l o rig in . K no w le dg e o f th e m o st
c om m o n les io ns , as w e ll as ba s ic c lin -
ic a l in fo rm ation , c an p ro v ide a p rio ri-
tize d lis t o f d ia gn ose s . U ltra sou nd
h as p ro ven to b e an op tim a l im ag ing
te chn iq ue be ca use it is sa fe a nd e ffi-
ca c iou s in neo na tes . F re qu en tly , u l-
tras ou nd is the on ly tes t req u ire d to
c on firm th e d ia gn os is . T he in crea se d
u se o f u ltra sou nd d uring p reg na ncy
h as d is c lo se d se ve ra l ab do m in a l
a no m alie s th a t a re co nn ec ta b le a n te n -
a ta lly . E stab lish m en t o fg u ide line s a d -
d res s in g the ind ica tio ns fo r a nd tim -
ing o f in u te ro in te rve n tion is a n on-
go in g an d a ra p id ly ch an g ing fie ld .
M o s t n eo n a ta l m a ss es are
b e n i g n .
T h e p urp ose o f th is p ape r ha s be en
to fa m ilia rize the p ra c tic in g p ed ia tn i-
c ian w ith a p ra c tica l sch em e by w h ich
a c on ne c t d ia gno s is ca n be exp ed i-
tio us ly o b ta in ed a nd m an ag em e n t in -
itia ted fo r n eo na te s w ith an a bd om i-
na l m as s . A n a lgo rith m (F ig 2 ) w as
fo rm u la ted to s um m ariz e th is p roc-
e ss . M a jo r em p ha s is is p la ced o n
a vo ida nc e o f ob ta in in g ad d itio na l
s tu d ies tha t w ill n o t a lte r the th e ra py
bu t m ay be exp en s ive , inc u r risk s ,
a nd /o r de la y ins titu tio n o f th e ap pro -
p n ia te t re a tm e n t.
T h e op tim a l e va lu a tion o f a n a b-
d om ina l m ass in the ne w bo rn is b es t
a ch iev ed b y ea rly co m m u n ica tion be -
tw ee n th e pe d ia tr ic ia n , pe d ia tr ic sun -
g eo n, a nd ra dio lo gis t.
S U GG ES TE D R E AD IN G
A d z ick N S , F la ke A W , H a rriso n M R . R ece n t
a d van ce s in p re n a ta l d iag n os is an d tre a t-
ment Pediatr lin
1985;32:11 3 1116
C o ra n A G , B e hre n d t D M , W e in trau b W H , e t a l.
Su rge ry o f the N eona te .
B os to n , M A: L ittle ,
B row n a n d C o; 1 97 8 :2 0 4 -2 33
H a rriso n M A , G o lb ou s M S , F illy B A , e t a l. F e ta l
h yd ron e ph ro s is : se le c tio n a nd s u rg ic a l re -
pa i r .
J P ed ia tr S urg .
1 9 8 7 ; 2 2 : 5 5 6 - 5 58
K irks D r, M erte n D F , G ro ss m an H , e t a l. D i-
a g no s tic im a g in g o f p ed ia tric a bd o m in a l
m as ses : a n o ve rv ie w .
R ad io ! C lln N o rth Am .
1 98 1 ; 1 9 :5 27 -5 45
S ieg e l M J , C la ib om e A K . Im a g ing o f a bd o m in a l
a n d p e lv ic m as ses in ch ild re n .
Cu rr P rob l
D ia gn R ad io !.
1 9 85 ;1 4 :1 -4 8
S te ve ns on R I. A bd om in a l m ass es .
Su rg C lin
N orth Am .
1985 ;65 :1481-1504
S elf-E v a lu a tio n Q u iz
7.
M ore th a n 5 0 o f n e o n a ta l a b d o m in a l
m as s e s o rig in a te fro m w h ic h o f th e fo llo w -
i ng s it es ?
A . R e na l sys te m .
B . G en ita l tra c t.
C . G as tro in tes tina l trac t.
D . R etrop eriton ea l (n on ren al).
E . L iv e r, b ilia ry tra c t, a n d sp lee n .
8 . A n a bd o m in a l ra d iog ra ph o f a n ew b orn
w ith an ab do m ina l
m a s s is lik e ly to s h o w
ab n orm al c a lc if ica tion s in
e a c h o f th e fo llo w -
i ng e xc ep t:
A . N e ur ob la st om a .
B . T er ato ma .
C . H e pa to bl as to m a.
D . H y dr on e ph ro s is .
E . M eco n ium p e rito n itis .
9.
W he n e v a lu a tin g n e o n a ta l a b d o m in a l
m a s s e s , w h ic h o f th e fo llo w in g s h o u ld b e
d o n e first?
A . C o m pu te d to m ograp hy .
B . A b do m ina l ra d io g ra p h a nd u ltras ou nd .
C . M a gn e tic re son a nce im ag in g .
0 . R a d io nu c lide sca n .
E . In tra ven ous p ye lo gra ph y.
10 . E a ch o f th e fo llo w ing a re
a d v a n ta g e s
o f a b d om in a l u ltra s o u nd , e x c e p t:
A . H arm les s.
B . Le ss e xpe n s ive .
C . N o se da tio n .
0 . A b le to pe rfo rm a t be ds id e .
E . A b ility to s ca n th ro u gh b on e a nd g a s .
I 1 . E a c h o f th e fo llo w in g is a tru e s ta te -
m en t a b o u t th e p ren a ta l d ia g n o s is a n d m an -
a g e m en t o f fe ta l a b d o m in a l m as s es , e x c e p t:
A . T h e inc rea se d us e o f fe ta l u ltras ou n d h as
p rov id ed a n o pp o rtun ity to p re na ta lly d i-
a gn o se a b do m ina l m asse s .
B Prenatal management of fetal intraab
d om in al m as se s i s l ar ge ly o b st et ri c in na -
tu re .
C P a t ie n t s w i t h u n i la t e ra l re n a l d i s ea s e ar e
b es t m an ag ed a ft er t er m de li ve ry
0 . In u te ro u rin a ry tra c t de co m p re ss io n
sh o u ld b e
cons idered
a s tan da rd ize d p ro -
ced u re o f p rov en va lu e .
E . S u cc ess fu l tre a tm e n t o f fe ta l u r in a ry tra c t
ob s truc tio n h a s
b e e n
lim ite d by th e in a -
b il ity to se lec t th e a pp ro p ria te fe tu s fo r
in te rven t ion .