What are the symptoms and signs to elicit in a patient with a palpable epigastric mass?

Symptoms and Signs to Elicit with Palpable Epigastric Mass

When evaluating a palpable epigastric mass, immediately assess for life-threatening conditions including perforated peptic ulcer (fever, abdominal rigidity, absent bowel sounds), acute pancreatitis (pain radiating to back), myocardial infarction (especially in women, diabetics, elderly), and mycotic aneurysm (fever with pulsatile mass), as these carry mortality rates of 10-30% if missed. 1, 2, 3

Critical Red Flag Symptoms Requiring Immediate Action

Peritoneal Signs Indicating Perforation

• Sudden, severe epigastric pain becoming generalized suggests perforated peptic ulcer with 30% mortality if treatment delayed 1, 2
• Abdominal rigidity, rebound tenderness, and absent bowel sounds indicate peritoneal contamination requiring immediate surgical consultation 1, 3
• Fever with masked liver dullness points to free intraperitoneal air from perforation 1

Vascular Emergency Signs

• Pulsatile epigastric mass with fever and back pain suggests mycotic aneurysm, present in 70% of cases with fever and 65-90% with back pain 1
• Severe pain with hemodynamic instability indicates impending or contained rupture of mycotic aneurysm, occurring in 50-75% of patients 1
• Recent aortic aneurysm repair history raises concern for aortoenteric fistula, developing in up to 4% of post-repair patients 1

Cardiac Presentation

• Epigastric pain with dyspnea mandates ECG within 10 minutes and serial troponins at 0 and 6 hours, as myocardial infarction presents atypically with epigastric pain in women, diabetics, and elderly with 10-20% mortality if missed 2, 3, 4

Malignancy-Associated Symptoms

Gastric Cancer Indicators

• Weight loss with palpable epigastric mass in patients ≥55 years requires 2-week wait endoscopy 1, 2, 3
• Early satiety, nausea, anorexia, and malaise commonly accompany gastric malignancies 1, 2
• Palpable and fixed epigastric mass indicates advanced disease and likely inoperability 1
• Supraclavicular lymphadenopathy (Virchow's node) signals metastatic spread and incurability 1

GIST Presentation

• Upper gastrointestinal bleeding and anemia are the most common presenting symptoms of GIST 1
• Abdominal pain/discomfort with palpable mass occurs with larger tumors 1
• Acute hemorrhage or rupture may be the first presentation of small bowel GIST after prolonged silent period 1
• Non-specific systemic symptoms including weight loss, night sweats, and fever can occur 1

Pancreatic Pathology Signs

Pancreatic Cancer Triad

• Pain, weight loss, and jaundice constitute the classic triad, though all three are rarely present together 1
• Persistent back pain indicates retroperitoneal infiltration and usually incurability 1, 2
• Severe and rapid weight loss suggests unresectability 1
• Palpable gallbladder with jaundice (Courvoisier's sign) points to pancreatic head or ampullary tumor 1

Pancreatitis Features

• Epigastric pain radiating to the back is characteristic, diagnosed by amylase ≥4x normal or lipase ≥2x normal with 80-90% sensitivity 2, 3
• Recent-onset diabetes mellitus in older patients without predisposing features warrants pancreatic cancer exclusion, as 5% develop diabetes within 2 years prior 1
• Unexplained acute pancreatitis attack should prompt investigation for underlying carcinoma in 5% of cases 1

Benign Mass Characteristics

Gastric Bezoar

• Abdominal pain, vomiting, weight loss, and halitosis in young females (especially girls aged 4-19 years) with palpable epigastric mass suggests trichobezoar 5
• History of trichophagia or pica supports bezoar diagnosis 5

Hepatic Cyst

• Increasing prominent epigastric mass with bloated feeling in obese patients may indicate giant liver cyst 6
• Intestinal compression symptoms occur when cysts reach significant size (≥20 cm) 6

Hernia

• Epigastric pain and vomiting with palpable 10-15 cm mass suggests epigastric hernia through linea alba defect 7

Associated Symptoms by System

Gastrointestinal

• Dysphagia indicates esophageal or gastroesophageal junction involvement 1, 2
• Hematemesis requires urgent endoscopy regardless of age 2, 3
• Persistent vomiting is an alarm feature mandating investigation 2, 3
• Gastrointestinal hemorrhage can be catastrophic with superior mesenteric or hepatic artery aneurysms 1

Hepatobiliary

• Jaundice with colicky upper abdominal pain and hemobilia suggests hepatic artery mycotic aneurysm 1
• Jaundice in body/tail pancreatic cancer usually indicates hepatic/hilar metastases and inoperability 1

Systemic

• Fever with leukocytosis (65-85%) and elevated inflammatory markers (75-80%) occur with mycotic aneurysms but are less common with inflammatory abdominal aortic aneurysms 1
• Migratory thrombophlebitis rarely presents as first symptom but can indicate pancreatic malignancy 1

Physical Examination Findings

Mass Characteristics

• Pulsatile quality distinguishes vascular aneurysms from solid masses 1
• Fixed and immobile suggests malignant infiltration and inoperability 1
• Lobulated surface with irregular borders may indicate GIST or other mesenchymal tumors 8
• Tenderness is non-specific but present with inflammatory conditions 1, 8

Associated Findings

• Ascites indicates advanced malignancy or contained aneurysm rupture 1
• Abdominal distension with masked liver dullness suggests free intraperitoneal air from perforation 1
• Anemia on examination warrants full blood count in patients ≥55 years 2, 3

Timing and Progression

• Sudden onset favors perforation, acute pancreatitis, or aneurysm rupture 1, 2
• Gradual increase over 3 months suggests benign cyst or slow-growing tumor 6, 8
• Long asymptomatic period before current illness occurs with aortoenteric fistula in patients with remote aneurysm repair 1

Special Population Considerations

Female Patients

• Gynecological symptoms including menstrual irregularities require consideration of ovarian pathology in reproductive-age women 4
• Pregnancy status must be determined as it complicates workup and imaging choices 4

Elderly and High-Risk Patients

• Age >40 years from high gastric cancer risk area or family history of gastroesophageal malignancy requires 2-week wait endoscopy 2
• History of cigarette smoking or diabetes mellitus increases risk of inflammatory abdominal aortic aneurysm 1