Abdominal Tumors
87 ABDOMINAL TUMORS
Frederick M. Karrer M.D., Denis D. Bensard M.D.
1. What are the most common malignant solid abdominal tumors in children?
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Neuroblastomas, Wilms’ tumors, and hepatoblastomas, in that order. Neuroblastomas are derived from neural crest tissue; in the abdomen, they originate from the adrenal glands and paraspinal sympathetic ganglia. Wilms’ tumor (nephroblastoma) derives from the kidney, and hepatoblastomas originate in the liver.
2. Is it tough to differentiate Wilms’ tumor from neuroblastomas clinically?
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Yes. Both tumors present as an asymptomatic abdominal mass. The differences are summarized in Table 87-1. In addition, because neuroblastomas produce hormones, affected children may exhibit flushing, hypertension (catecholamine release), watery diarrhea, periorbital ecchymosis, and abnormal ocular movements.
Table 87-1. DIFFERENTATION BETWEEN WILMS’ TUMOR AND NEUROLASTOMA
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Wilms’ Tumor
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Neuroblastoma
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|
|
Age at presentation
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3-4 yr
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1-2 yr
|
|
Extend across midline
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Rare
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Common
|
|
Surface on palpation
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Smooth
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Knobby
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|
X-ray calcifications
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No
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Yes
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3. How are Wilms’ tumors and neuroblastomas treated?
Table 87-2. TREATMENT OF WILMS’ TUMOR AND NEUROBLASTOMA
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Wilms’ Tumor
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Neuroblastoma
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|
|
Primary surgical excision
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Important (likely)
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Important (less likely)
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|
Chemotherapy
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Enormous impact
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Less responsive
|
4. What are the major prognostic factors in neuroblastomas and Wilms’ tumor?
In neuroblastomas, age at presentation is the major prognostic factor. Children younger than 1 year have an overall survival rate > 70%, whereas the survival rate for children older than 1 year is < 35%. Shimada proposed a prognostic classification based on evaluation of histologic parameters (tumor differentiation, mitosis-karyorrhexis index [MKI]) as well as age. Aneuploid tumors, tumors with low MKI, and tumors with < 10 copies of the n-myc gene also have better outcomes.
Age is also important in children with Wilms’ tumors, but the prognosis is better because the tumors are more readily excised and much more sensitive to chemotherapy.
5. What are the differences between hepatoblastomas and hepatocellular carcinomas? How are the tumors treated?
Hepatoblastomas usually occur in infants and young children, whereas hepatocellular carcinoma usually occurs in children older than 10 years. Hepatocellular carcinoma usually is associated with cirrhosis and hepatitis B and is histologically identical to the adult form. Surgical resection is the primary therapy for both tumors. Hepatoblastomas often have a good response to adjunctive chemotherapy, whereas hepatocellular carcinoma rarely responds to chemotherapy.
Inguinal Hernia. Controversies
CONTROVERSIES
36. What are some of the anatomic issues related to inguinal hernias?
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At issue is the iliopubic tract, which is central to the Anson/McVay anatomic description of the inguinal area and featured in the McVay Cooper’s ligament repair. Although the McVay repair is used in England, the iliopubic tract is not referred to or described in English anatomic texts.
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Inguinal Hernia
56 INGUINAL HERNIA
Gregory P. Victorino M.D., Jyoti Arya M.D., James Bascom M.D.
1. “Groin” hernia refers to which three hernias?
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Direct and indirect inguinal hernias and femoral hernias.
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Anorectal Disease. Pilonidal Sinus Disease
PILONIDAL SINUS DISEASE
29. What is the most common clinical presentation of a pilonidal sinus?
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Pain and swelling in the sacrococcygeal region, which typically are associated with a (sometimes several) chronic draining sinus tract.
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Anorectal Disease. Hemorrhoids
HEMORRHOIDS
21. What are hemorrhoidal tissues, and what are their normal functions?
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Hemorrhoids are cushions of vascular tissue that contribute to anal continence and protect the sphincter mechanism during defecation. Hemorrhoids are not veins, but sinusoids. Bleeding originates from presinusoidal arterioles, thus explaining the bright red arterial color.
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Anorectal Disease. Anal Fissure
ANAL FISSURE
14. What is the most common location for idiopathic anal fissure?
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90% are posterior, and 10% are anterior.
15. What are the most common symptoms of anal fissure?
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Tearing anal pain and bleeding with bowel movements.
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Anorectal Disease. Anorectal Abscess & Fistula In Ano
ANORECTAL ABSCESS AND FISTULA IN ANO
5. What is the most common cause of anorectal abscess?
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Ninety percent result from cryptoglandular infection.
6. What are the four potential anorectal spaces used to classify anorectal abscesses?
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1. Perianal (area of the anal verge)
2. Ischiorectal (area lateral to the external sphincter muscles, extending from the levator ani muscles to the perineum)
3. Intersphincteric (area between the internal and external sphincter muscles, continuous inferiorly with the perianal space and superiorly with the rectal wall)
4. Supralevator (area superior to the levator ani muscles, inferior to the peritoneum, and lateral to the rectal wall)
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Anorectal Disease
55 ANORECTAL DISEASE
Eric L. Sarin M.D., John B. Moore M.D.
1. What aspect of the initial patient encounter is most important in the diagnosis of anorectal disease?
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Clinical history, including duration of complaints, exacerbating or alleviating issues, precipitating events, dietary and bowel habits, and current or previous treatments. This may not sound glamorous, but you will never encounter a more grateful patient than one whose rectal problem you have solved.
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Colorectal Carcinoma
54 COLORECTAL CARCINOMA
Kathleen Liscum M.D.
1. What are the top three causes of cancer deaths in the United States?
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Lung, breast or prostate, and colon cancer.
2. List a few of the presenting symptoms of patients with colorectal cancer.
Show answer
Intermittent rectal bleeding, vague abdominal pain, fatigue secondary to anemia, change in bowel habits, constipation, tenesmus, and perineal pain.
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Colorectal Polyps
53 COLORECTAL POLYPS
Carlton C. Barnett Jr. M.D., Michael B. Wallace M.D., M.P.H.
1. What are polyps?
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A polyp is an elevation of the mucosal surface that can occur anywhere in the gastrointestinal (GI) tract. Two thirds of polyps occur in the rectosigmoid and descending colon.
2. What are the major types of polyps?
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1. Pedunculated polyps have a head attached by a stalk to the mucosa of the colon or rectum. The stalk usually is covered with normal mucosa.
2. Sessile polyps rest on a broad base.
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Lower Gastrointestinal Bleeding
52 LOWER GASTROINTESTINAL BLEEDING
Kathleen Liscum M.D.
1. Describe the treatment of a patient who presents with lower gastrointestinal (GI) bleeding.
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Treatment begins with the ABCs (airway, breathing, circulation). Place two large-bore intravenous (IV) catheters in the upper extremities. Obtain hemoglobin and hematocrit levels, blood type, and cross-match. A Foley catheter should be placed to help monitor volume status.
2. What is the next step in evaluating the patient?
Show answer
A nasogastric tube should be placed to rule out an upper GI source. If the aspirate is bilious, the examiner can be fairly certain that the source is distal to the ligament of Treitz. However, if the aspirate reveals no bile, the patient may still be bleeding in the duodenum with a competent pylorus.
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UPPER GASTROINTESTINAL BLEEDING
51 UPPER GASTROINTESTINAL BLEEDING
G. Edward Kimm Jr. M.D., Allen T. Belshaw M.D.
1. What is upper gastrointestinal (GI) bleeding?
Show answer
Bleeding from proximal to the ligament of Treitz (the transition point between duodenum and jejunum).
2. What are the most common causes of upper GI bleeding?
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In descending order of frequency, they are gastritis, duodenal ulcer, esophageal varices, benign gastric ulcer, esophagitis, and Mallory-Weiss tear. All other causes account for < 5% of cases.
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Inflammatory Bowel Disease. Controversies
CONTROVERSIES
17. Should all patients with enteroenteral fistulas secondary to Crohn’s disease have surgery when the fistula is discovered?
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For: Such patients ultimately do poorly, develop further intraperitoneal septic complications, and almost always require surgery.
Against: Many of these patients do well without operative treatment until they develop symptoms. It is fine to wait for symptoms.
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Inflammatory Bowel Disease
50 INFLAMMATORY BOWEL DISEASE
Anthony J. LaPorta M.D., Gilbert Hermann M.D.
1. What two clinical entities encompass the diagnosis of inflammatory bowel disease?
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Crohn’s disease and ulcerative colitis (acute or chronic).
2. Although the two diseases often overlap, they usually can be distinguished by clinical criteria. What are the major clinical differences?
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Rectal bleeding is unusual in Crohn’s disease but common in chronic ulcerative colitis. An abdominal mass and anal complications (fissure, fistula) are more common in Crohn’s disease.
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Acute Large Bowel Obstruction
49 ACUTE LARGE BOWEL OBSTRUCTION
Elizabeth C. Brew M.D.
1. What are the mechanical causes of large bowel obstruction?
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The three most common mechanical causes are carcinoma (50%), volvulus (15%), and diverticular disease (10%). Extrinsic compression from metastatic carcinoma is another cause of obstruction. Less frequent causes include stricture, hernia, intussusception, benign tumor, and fecal impaction.
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Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
