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abdominal symptoms. The differential diagnosis of a pancreatic mass includes
nonmalignant adenoma or cystadenoma as well as malignant entities. Malignant
tumors of the pancreas in children may be cystadenocarcinoma, pancreatoblastoma,
an embryonal tumor, or an endocrine tumor such as insulinoma, gastrinoma, or
VIPoma ( Table 98.6 ). The pancreas may also be affected by metastatic disease
from end-stage refractory cancer such as neuroblastoma or rhabdomyosarcoma.
A thorough history and physical examination should assess for endocrinologic
ramifications that require medical management, such as hypoglycemia. The
evaluation should include a serum AFP, which can be elevated in
pancreatoblastoma. Diagnostic imaging may include a CT scan or MRI of the
abdomen, but these tests are rarely needed in the ED.
The patient with a newly diagnosed pancreatic tumor may be discharged to home
if the patient is otherwise well appearing and if arrangements have been made for an
appropriate evaluation, including consultation with a pediatric surgeon, to continue
in the outpatient setting. If the patient is ill, or if appropriate follow-up is unclear,
then it is safest to admit the patient to the hospital. Surgical intervention is an
important facet of the management plan for patients with pancreatic tumors, as
several pancreatic tumors may be managed with surgery alone.

Tumors of the Gastrointestinal Tract
Tumors in the gastrointestinal (GI) tract in children include lymphomas, leukemias,
gastrointestinal stromal tumors (GISTs), LCH, desmoplastic small round cell tumor,
and colorectal carcinomas ( Table 98.6 ). Risk factors for GI lymphomas include
primary immunodeficiency. Neurofibromatosis type 1 increases the risk of GIST.
FAP, Li–Fraumeni syndrome, and ulcerative colitis increase the risk of colon cancer.
Common presentations include nonspecific symptoms such as weight loss,
nausea/vomiting, loss of appetite, change in bowel habits, abdominal distention, or
abdominal pain. Chronic GI blood loss can cause iron-deficiency anemia.
Abdominal distention from masses or ascites may be present. Severe GI bleeding is
a rare presentation of GI malignancy but one that requires immediate management
as in Chapter 33 Gastrointestinal Bleeding . Symptoms of intermittent GI

obstruction may be present. Complete obstruction is an extremely rare presentation
and may require urgent surgical intervention. The lead point for intussusception in
children older than 3 years may be a primary GI lymphoma. Incidental findings on
appendectomies in children can include Burkitt lymphoma or carcinoid tumor.
Lymphomas involving the GI tract and/or mesenteric nodes in children include
Burkitt lymphoma and large cell lymphoma ( Table 98.5 ). Advanced Burkitt
lymphoma should be suspected in patients with a rapidly evolving clinical picture of
progressive abdominal distention, abdominal masses, and/or ascites with associated
elevation in uric acid, LDH, or renal insufficiency. Colorectal carcinoma is