What is the appropriate evaluation and management approach for a patient presenting with a palpable epigastric mass?

Evaluation of a Palpable Epigastric Mass

For a patient presenting with a palpable epigastric mass, obtain CT abdomen and pelvis with IV contrast and neutral oral contrast as the initial imaging study, followed by endoscopy with biopsy if gastric pathology is suspected. 1

Critical History Elements to Elicit

When evaluating a palpable epigastric mass, document these specific clinical features that directly impact management:

• Mass characteristics: Measure size in centimeters, assess for well-defined versus irregular margins, mobility, consistency, and any attachment to skin or deep fascia 2
• Red flag symptoms: Weight loss, early satiety, persistent vomiting, or gastric outlet obstruction symptoms suggest malignancy 1
• Age and risk factors: Gastric adenocarcinoma has an incidence of 7.3 per 100,000 with a 5-year survival of only 32%, making early detection critical 1
• Location relative to anatomical landmarks: This determines whether the mass originates from stomach, liver, pancreas, or abdominal wall 2, 3

Initial Imaging Algorithm

CT abdomen and pelvis with IV contrast is the appropriate first-line imaging study for evaluating an epigastric mass when gastric cancer or other intra-abdominal pathology is suspected 1. The examination must include:

• IV contrast administration: Essential for detecting nodular wall thickening, soft tissue attenuation of gastric wall thickening, and assessing for lymphadenopathy and distant metastases 1
• Neutral oral contrast: Water or dilute barium suspension helps delineate the intraluminal space and improves visualization of gastric wall abnormalities 1
• Pelvis inclusion: Necessary for detecting distant metastases and evaluating overlapping symptoms 1

CT without IV contrast is significantly less sensitive and should be avoided 1. The ACR guidelines explicitly state there is limited value in performing CT without contrast for this indication 1.

Alternative Imaging Considerations

While ultrasound has 95% sensitivity for abdominal aortic aneurysm and can serve as an initial modality for some abdominal masses 2, CT provides superior characterization of gastric and solid organ pathology 1. If ultrasound is performed first and identifies a solid mass requiring further characterization, proceed immediately to CT with thin-section imaging (≤5 mm slices) with IV contrast 2.

Endoscopic Evaluation

Upper endoscopy with biopsy is the reference standard for diagnosing gastric cancer and should be performed when CT demonstrates concerning gastric findings 1. Key imaging findings on CT that warrant endoscopy include:

• Nodular or irregular gastric wall thickening 1
• Soft tissue attenuation of wall thickening (rather than low attenuation edema) 1
• Ulcerated mass with perforation 1
• Regional lymphadenopathy 1

Gastric masses may not be well visualized on CT if the stomach is underdistended, but other concerning features may still be apparent 1. Therefore, negative CT findings should not preclude endoscopy if clinical suspicion remains high.

When to Obtain Tissue Diagnosis

Image-guided core needle biopsy should be obtained if imaging reveals irregular margins, rapid growth, size >2 cm, or any concern for malignancy 2. Core needle biopsy is superior to fine needle aspiration for diagnostic accuracy, sensitivity, specificity, and histological grading 2.

For gastric subepithelial masses, endoscopic ultrasound (EUS) with tissue sampling may be indicated for lesions ≥3 cm or those with concerning endosonographic features such as irregularity of the extraluminal border, cystic spaces, echogenic foci, or heterogeneity 1.

Critical Clinical Pitfalls

Never allow negative imaging to overrule a highly suspicious physical examination—tissue sampling is warranted regardless of imaging appearance 2. Physical examination alone cannot reliably distinguish benign from malignant masses 2.

Do not perform biopsy before imaging, as biopsy-related changes will confuse, alter, obscure, and limit subsequent image interpretation 2, 4, 5. This principle applies universally to all palpable masses.

Avoid MRI as initial imaging for epigastric masses—MRI is not routinely used to diagnose gastric pathology, and CT is preferred because of its ability to detect free air from perforated ulcers and shorter acquisition time 1.

Differential Diagnosis Considerations

Common causes of epigastric masses include:

• Gastric malignancy: Now the most common cause of gastric outlet obstruction in adults due to decreased PUD incidence from widespread H2 blocker use 1
• Hepatomegaly or liver cysts: May present as prominent epigastric masses, particularly in obese patients 6
• Pancreatic pathology: Pseudocysts or malignancy 3
• Abdominal wall hernias: Epigastric hernias through linea alba defects 7
• Rare entities: Xiphisternal tuberculosis, gastric carcinosarcoma, or parasitic infections 8, 3, 9

Management of Specific Lesion Types

For gastric subepithelial masses ≥3 cm (likely GISTs), complete surgical resection with clear margins is indicated—local excision is adequate without need for wide margins or lymph node dissection 1. Laparoscopic approaches achieve success rates exceeding 90% with shorter hospital stays, though local recurrence rates range from 0-30% 1.

For gastric carcinoid tumors, type 1 and 2 require only local excision, while type 3 carcinoids demand partial or total gastrectomy with lymph node dissection due to aggressive behavior 1.