Pediatric emergency medicine trisk 2704 2704
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ED, emergency department; ABO, blood group system; Rh, Rheus (Rh) blood group system; WBC, white blood
cell; CMV, cytomegalovirus; HLA, human leukocyte antigen; h/o, history of; pRBC, packed red blood cells.
The differential diagnosis of a pediatric renal mass also includes benign lesions
such as hydronephrosis, multicystic or polycystic kidneys, and mesoblastic
nephroma. A renal mass in a neonate is less likely to be malignant and more likely a
congenital malformation of the genitourinary (GU) tract. Both neuroblastoma and
Wilms tumor most commonly develop in the 1- to 5-year age range. Other less
common malignant tumors include rhabdoid tumor of the kidney, clear cell sarcoma,
and mesoblastic nephroma. Carcinomas, including medullary carcinoma and renal
cell carcinoma, are extremely rare. Hematologic malignancies often metastasize to
the kidney but rarely present with a solitary lesion.
Clinical Considerations
Clinical Recognition
Wilms tumors most commonly present with a painless mass found incidentally by
either the parents or pediatrician in a child who is otherwise well appearing (see Fig.
98.2 ). Masses are deep in the flank, smooth, and may be firm or soft. Wilms tumor
may have more serious or life-threatening presentations including the following:
Hypertension due to increased renin secretion from renal artery compression, in
less than 15% of cases;
Gross hematuria in less than 25% of cases (although microscopic hematuria is very
common);
Hematologic complications such as anemia, tumor thrombus in the renal veins
with or without extension into the inferior vena cava; and
Abdominal compartment syndrome from a massive renal tumor in a very small
child.
Clinical Assessment
A thorough history and physical examination is needed, including assessment of
measured blood pressure against normal values for age. Because Wilms tumor can
be associated with other syndromes, such as Beckwith–Wiedemann syndrome and
WAGR (Wilms tumor, Aniridia, GU anomalies, Range of developmental delays)
syndrome, the physical examination should screen for physical anomalies that may
signal that the renal mass is part of a larger picture. The clinician should assess and
treat pain as needed. Laboratory evaluation should include a CBC to look for
evidence of bleeding, a urinalysis, and liver and renal function testing (BUN and
creatinine). Serum calcium may be elevated in rhabdoid tumor of the kidney or
congenital mesoblastic nephroma.
