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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 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 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