What is the diagnosis and management for a 68-year-old male presenting with chest pain radiating to the abdomen, recent onset of bowel symptoms, negative cardiac exam, negative troponin (cardiac biomarker), normal Myocardial Perfusion Imaging (MPI) and echocardiogram (echo), positive D-dimer (blood test for thrombosis), and a 13.4cm heterogeneous mass in the right hepatic lobe on Computed Tomography (CT) chest?

Diagnosis and Immediate Management

This patient's chest pain radiating to the abdomen with negative cardiac workup, positive D-dimer, and a large 13.4cm hepatic mass most likely represents a non-cardiac etiology requiring urgent evaluation for malignancy, hepatic complications (rupture, hemorrhage), or thromboembolic disease. 1

Cardiac Etiology Effectively Ruled Out

The comprehensive cardiac evaluation has appropriately excluded acute coronary syndrome:

• Negative troponin, normal MPI, and normal echocardiography effectively exclude major myocardial infarction and significant cardiac ischemia 1
• The absence of wall motion abnormalities on echocardiography excludes major myocardial infarction 1
• Normal myocardial perfusion imaging effectively rules out significant coronary ischemia 1

Primary Diagnostic Considerations

Most Urgent: Hepatic Mass Complications

The 13.4cm heterogeneous hepatic mass with chest pain radiating to abdomen raises immediate concern for:

• Hepatic tumor rupture or hemorrhage - Large hepatic masses can cause capsular distension leading to referred pain to chest and abdomen, and spontaneous rupture represents a life-threatening emergency 2, 3
• Malignancy-associated thromboembolism - The positive D-dimer in context of a large hepatic mass suggests possible pulmonary embolism or hepatic vein thrombosis (Budd-Chiari syndrome) 1, 4

Constipation and Bowel Obstruction

• Five days without bowel movement suggests possible bowel obstruction, which can cause referred chest pain and abdominal discomfort 2, 5
• Abdominal distension and constipation strongly suggest bowel obstruction 2

Immediate Diagnostic Algorithm

Step 1: Complete CT Abdomen/Pelvis with IV Contrast (URGENT)

Proceed immediately with CT abdomen/pelvis as already advised to evaluate:

• Hepatic mass characteristics (primary hepatocellular carcinoma vs metastatic disease vs benign lesion) 2, 3
• Evidence of hemorrhage, rupture, or capsular breach 3
• Hepatic vein patency (exclude Budd-Chiari syndrome) 3
• Bowel obstruction presence and level 2, 5
• Peritoneal free fluid or free air 5

Step 2: Evaluate for Pulmonary Embolism

Given positive D-dimer and large hepatic mass (malignancy risk), assess for PE:

• Review existing CT chest images specifically for pulmonary embolism 1, 4
• If CT chest was not performed with PE protocol, consider CT pulmonary angiography 1, 4
• Malignancy significantly increases thromboembolism risk, making PE a critical consideration 4, 6

Step 3: Additional Laboratory Evaluation

Obtain immediately:

• Complete blood count (assess for anemia from hemorrhage, leukocytosis from infection/necrosis) 7, 2
• Comprehensive metabolic panel (liver function tests, renal function) 2
• Coagulation studies (PT/INR, PTT) given concern for hepatic dysfunction 2
• Alpha-fetoprotein (AFP) if hepatocellular carcinoma suspected 2
• Lactate (if bowel ischemia concern) 5

Critical Management Priorities

Immediate Stabilization

• Maintain NPO status given possible surgical intervention 2, 5
• Establish large-bore IV access and initiate fluid resuscitation - Patient has been constipated for 5 days suggesting possible dehydration 5
• Pain control with IV opioids (morphine 4-8mg with 2mg increments every 5 minutes) 1
• Continuous cardiac monitoring despite negative cardiac workup, given positive D-dimer and potential for hemodynamic instability 1, 6

Urgent Surgical Consultation

Obtain immediate general surgery consultation for:

• Possible hepatic mass rupture requiring emergent intervention 2, 3
• Bowel obstruction management 2, 5
• Potential need for emergent laparotomy if imaging reveals catastrophic abdominal pathology 5

Oncology Consultation

Arrange urgent oncology evaluation once imaging confirms malignancy to establish tissue diagnosis and staging 2

Common Pitfalls to Avoid

• Do not dismiss abdominal pathology as the cause of chest pain - Chest pain radiating to abdomen frequently represents intra-abdominal disease, particularly hepatic or upper GI pathology 2, 3
• Do not delay CT abdomen/pelvis - This is the single most important diagnostic test and should be performed emergently 2, 3
• Do not ignore positive D-dimer despite negative cardiac workup - Malignancy-associated thromboembolism remains a critical consideration 1, 4
• Do not assume constipation is benign - Five days without bowel movement may represent mechanical obstruction from mass effect or malignant involvement 2, 5

Most Likely Diagnosis

Based on the clinical presentation, the most likely diagnosis is a large primary hepatic malignancy (hepatocellular carcinoma or metastatic disease) with complications including capsular distension causing pain, possible hemorrhage, and secondary bowel obstruction from mass effect. 2, 3 The positive D-dimer raises additional concern for malignancy-associated venous thromboembolism. 1, 4