Epigastric Mass - Bailey & Love's Short Practice of Surgery (28th Ed.)

Differential Diagnosis

Clinical Features

History

• Weight loss (most common with gastric/pancreatic malignancy)
• Anorexia and early satiety (gastric outlet obstruction or linitis plastica)
• Dyspepsia unresponsive to PPIs
• Dysphagia (GOJ involvement)
• Vomiting - projectile suggests gastric outlet obstruction; succussion splash
• Haematemesis or melaena (ulcerating gastric carcinoma)
• Jaundice (pancreatic head cancer, hepatic metastases)
• Back pain (pancreatic cancer with retroperitoneal invasion)
• Thrombophlebitis / DVT - Trousseau's sign (non-metastatic effect of gastric malignancy)

Examination

• Visible peristalsis suggests gastric outlet obstruction
• Distension pattern
• Jaundice, cachexia, anaemia

• A mass from the anterior abdominal wall becomes more prominent on tensing muscles (Valsalva/straight leg raise); a deep mass becomes less palpable
• Lumps in the muscle layer become fixed on tensing
• Lumps deep to the abdominal wall (intra-abdominal) move freely unless fixed by adhesions or invasion
• Epigastric hernia: midline swelling in linea alba, may have cough impulse, usually not reducible (narrow neck), locally tender
• Pulsatile mass = AAA (expansile, not just transmitted pulsation)
• Move with respiration = liver/spleen/kidney attachment
• Mesenteric cyst moves perpendicular to root of mesentery
• If moveable transversely = uterine or ovarian mass

• Succussion splash (gastric stasis / outlet obstruction) - audible with shaking the abdomen > 3 hours post meal
• High-pitched bowel sounds = early obstruction
• Aortic bruit = vascular pathology

• Virchow's node (Troisier's sign) - left supraclavicular lymph node
• Sister Mary Joseph's nodule - periumbilical nodule (omental/peritoneal metastasis)
• Krukenberg tumour - ovarian metastasis (found on PV examination)
• Hepatomegaly - irregular, hard
• Ascites - shifting dullness, fluid thrill

Investigations

Blood Tests

• FBC: anaemia (iron deficiency from chronic blood loss, or B12 deficiency)
• LFTs: raised ALP/bilirubin in hepatic/biliary involvement
• Serum amylase/lipase: elevated in pancreatic pathology
• U&E: hypokalaemic hypochloraemic metabolic alkalosis in prolonged vomiting / gastric outlet obstruction
• Tumour markers: CEA, CA 19-9 (pancreatic), CA 72-4 (gastric)
• Albumin/nutrition markers: hypoalbuminaemia suggests malnutrition/malignancy
• Clotting: if operative planning

Endoscopy

• Upper GI endoscopy (OGD) is the first-line investigation for suspected gastric pathology - more sensitive than barium studies
• Biopsy any lesion (multiple biopsies for accuracy)
• CLO test for H. pylori

Imaging

• Ultrasound abdomen: first-line for epigastric mass - distinguishes solid from cystic, identifies hepatic metastases, assesses biliary tree, detects ascites; AAA screening
• CT chest/abdomen/pelvis with IV contrast (staging CT): defines extent, vascular involvement, nodal disease, peritoneal deposits, resectability
• Endoscopic ultrasound (EUS): best for T-staging of gastric/pancreatic lesions and sampling regional nodes
• PET-CT: used for distant metastasis detection in curative intent cases
• Barium meal/swallow: largely superseded but may show classic "leather bottle stomach" (linitis plastica) or "rat-tail" deformity
• MRI: MRCP for biliary/pancreatic ductal anatomy; liver MRI for characterising hepatic lesions
• Diagnostic laparoscopy: mandatory before curative gastrectomy to exclude peritoneal disease not seen on CT

Histopathology

• Biopsy at endoscopy
• EUS-guided FNA for pancreatic/nodal lesions
• CT-guided percutaneous biopsy for retroperitoneal/hepatic lesions

Management

Gastric Carcinoma (most common cause of malignant epigastric mass)

• Early gastric cancer (T1, any N) = confined to mucosa/submucosa; 5-year survival ~90%
• Advanced = involves muscularis propria and beyond; Borrmann Types III/IV = often incurable

• Total or subtotal gastrectomy with D2 lymphadenectomy (standard in East Asia; accepted in specialist Western centres)
• Roux-en-Y reconstruction after total gastrectomy
• Perioperative chemotherapy (FLOT regimen: docetaxel, oxaliplatin, leucovorin, 5-FU) - improves overall survival
• For GOJ cancers: extended total gastrectomy or Ivor-Lewis oesophagogastrectomy

• Endoscopic stenting for gastric outlet obstruction
• Laparoscopic or open gastrojejunostomy bypass
• Palliative chemotherapy (first-line: platinum + fluoropyrimidine ± trastuzumab if HER2+)
• Radiotherapy for haemostasis or local control
• Nutritional support (jejunal feeding tube)

Pancreatic Mass

• Resectable head of pancreas: Whipple's procedure (pancreaticoduodenectomy)
• Body/tail: distal pancreatectomy ± splenectomy
• Pseudocyst: endoscopic or surgical cystogastrostomy if symptomatic

Epigastric Hernia

• Small/asymptomatic: conservative (may resolve spontaneously via fat infarction)
• Symptomatic: open repair (excise fat, close linea alba defect with non-absorbable sutures) or laparoscopic mesh repair (similar to umbilical hernia repair - defect hidden behind falciform ligament which must be taken down)
• Bowel-containing hernias: always repair

AAA

• < 5.5 cm: surveillance
• ≥ 5.5 cm or symptomatic: elective EVAR or open repair
• Ruptured: emergency surgery

Epigastric Hernia - Summary (Bailey & Love)

• Arise through the linea alba between xiphoid and umbilicus
• Defect usually < 1 cm, elliptical from transverse split in raphe
• Contents: extraperitoneal fat (mushroom-shaped); rarely bowel
• Common in fit young men, also obese multiparous women
• Very painful for small size due to partial strangulation of fat
• May mimic lipoma; cough impulse variable; usually irreducible
• Multiple hernias common - check carefully at repair or "recurrence" is missed second hernia