A mass in the epigastrium

POM Class on Thursday 11th September 2014

In our next POM class let us discuss the case of a mass in the epigastrium. The
whole class takes place in this exercise. Please read all the relevant information. I
give you the hints as what to be prepared. You have to divide into groups and
discuss the different aspects of this case.
Goal: At the end of the class all students of the class should be able to know:
1.
2.
3.
4.

Differential diagnosis of a mass in the epigastrium

What are the investigations that are required?
What is that each investigation reveals?
What is CEA (Carcinoembryogenic antigen)? How useful it is in the diagnosis
of cancer of stomach.

Following gist has to be discussed and understood at the end of the class:
Five conditions that have to be discussed in this case are:
1.
2.
3.
4.
5.

Carcinoma of stomach
Carcinoma of transverse colon
Aneurysm of the abdominal aorta
Pancreatic tumour or pseudocyst
Retroperitoneal lymphadenopathy

Five investigations that have to be discussed are:

1.
2.
3.
4.
5.

Abdominal ultrasound
Barium meal
CT scan of the abdomen
Endoscopy
CEA (given above) levels

Points to be remembered:

Malignancies of the gastrointestinal tract (gastric, pancreatic and colonic

cancers) are common conditions in USA and Europe
An increased risk of GI malignancies occurs in the case pernicious anaemia,
ulcerative colitis and polyposis
Patients with gastric cancer usually present with anorexia, weight loss, upper
abdominal discomfort, and distension even after taking small meals.
GI blood loss is common and therefore diagnosis of gastric cancer is made
after barium meal/endoscopy while one is trying to look at the cause of
anaemia
Histological confirmation of diagnosis through endoscopy biopsy is essential

Although colonic cancer is most common in the rectosigmoid region,

transverse colon may also be affected
Besides an epigastric mass, a patient with carcinoma of transverse colon may
present with anaemia and discomfort.
A change in the bowel habit is an early feature of carcinoma of descending
colon
Since the bowel contents remain liquid in the case of cancer of ascending and
transverse colon, features of changed bowel habits and obstruction are not
common until the late stage
Carcinoma of the head of the pancreas typically presents with nausea,
anorexia, weight loss, and progressive painless jaundice
With carcinoma of the body of the pancreas, the symptoms are often illdefined and consist of vague upper abdominal pain that may be worse on
lying down and may occasionally refer to the back
The formation of a pseudocyst is a common complication of acute
pancreatitis (it is a pseudocyst because it has no epithelial lining as
compared to a true cyst). The pseudocyst contains necrotic tissue, blood, and
pancreatic secretion and its walls are formed by the surrounding structures.