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  • 8/18/2019 Res Lounge Abdominal-masses

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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

  • 8/18/2019 Res Lounge Abdominal-masses

    7/8

    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

  • 8/18/2019 Res Lounge Abdominal-masses

    8/8

    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 .