My tummy hurts!

Authors: Thomas MacMahon / Editor: Turlough Bolger, Steve Corry-Bass / Codes: HCPS4i / Published: 24/01/2019

A 5-year-old boy is brought in by his father with a 4 month history of intermittent abdominal pain, mainly at night, which is now waking him from sleep. His parents feel his abdomen has become distended. He has no vomiting or diarrhoea. He has daily soft bowel motions. His appetite is slightly reduced but his energy levels are good. He attends school, which he enjoys.

He has no other medical problems, medications or allergies. His vaccines are up to date. He has two brothers, both of whom are well.

He is chatty and alert when you see him. His temperature, pulse, oxygen saturations and respiratory rate are within normal limits. His blood pressure is elevated at 149/118mmHg (systolic blood pressure 50th centile for his age is 95mmHg).

ENT, cardiovascular, respiratory and neurological examinations are unremarkable. His capillary refill time is normal. You palpate a large, smooth, firm, non-tender mass in his right upper quadrant, which extends towards the midline and down to the right lower quadrant. There are no bruits or regional lymphadenopathy. Bowel sounds are present.

Urinalysis shows 2+ protein and 4+ blood. Full blood count is normal. His creatinine is slightly elevated (49 mmol/l) but the remainder of his electrolytes, liver function tests, bone profile and CRP are normal. Chest x-ray is normal. Ultrasound shows a large mass in the right renal fossa.

You organise an urgent contrast enhanced CT of his thorax, abdomen and pelvis, a coronal image from which is below.

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