Abdominal Aortic Aneurysm Case studies- 1. A 62 year old security guard at an emergency room approaches the physician with the complaint of epigastric pain and nausea. is it anything I should worry about?, he asks. The patient appears worried and appears to be in significant discomfort. His initial evaluation reveals VPC's and epigastric tenderness but no aneurysm is appreciated. EKG is otherwise normal however he is admitted. Further evaluation reveals a abdominal aortic aneurysm which is successfully resected. 2. A 59 year old male is in the ER undergoing a workup of right flank pain. Results of a urinalysis are pending but the degree of pain is great. Suddenly he becomes hypotensive. He is resuscitated with IV fluids. He is brought to surgery where a leaking abdominal aortic aneurysm is found. Retrospectively his blood pressure was 90/70 upon admission. 3. A 72 year old male is seen in the emergency room with severe left lower quadrant pain. He has been seen twice elsewhere and place on antibiotics for acute diverticulitis. His diagnosis is leaking abdominal aortic aneurysm which becomes apparent early in the course of his evaluation. 4. A 75 year old female has chronic back pain treated by her doctor. She appears in the emergency room complaining of worsening of left lumbar pain and also states that there is something different about the pain. An initial provider diagnoses lumbosacral sprain and prescribes analgesics. A second provider reevaluates the patient and palpates a pulsatile supraumbilical abdominal mass which is slightly tender. A CT scan reveals a five centimeter abdominal aortic aneurysm which is not leaking. Surgery is advised but the pain subsides in a few hours and the patient discharges herself against medical advice and wants to get a second opinion. The actual cases above are meant to show that abdominal aortic aneurysm, while not an everyday finding, is not uncommon and must be considered in all cases of abdominal and back pain particularly in those over 50 years of age, with a a history of hypertension, atherosclerotic cardiovascular disease, While there are other causes these are the most common. An aneurysm is a weakness in the vessel wall that gradually balloons out under pressure and often ruptures or leaks. For practical purposes abdominal aortic aneurysms may be thought of as either symptomatic, causing pain, bruit or pulsatile mass, or asymptomatic, detected only on careful physical exam or by XRAY, CT or MRI, or abdominal sonogram. A symptomatic abdominal aortic aneurysm requires emergent surgery because pain or appreciation of a pulsatile mass in the abdomen can mean stretching of the tissue around the aorta and this means immanent rupture. Surgery consists of resection of the aneurysm and replacement of the removed blood vessel with a graft. Today surgical treatment is effective making clinical diagnosis of the problem all the more valuable. The diameter of the aorta is about 2 to 3 cms in the adult. Aneurysms are generally around 4cms. Theoretically any size aneurysm may become symptomatic and go on to rupture but the risk is greater as the size approaches 5 cms. Asymptomatic abdominal aortic aneurysms are those found on careful examination or by XRAY, CT or MRI , or abdominal sonogram. Once it is determined that the aneurysm is not in danger of immanent rupture, these patients must be referred to a vascular surgeon for evaluation not only for surgery but to determine their risk of other complications of ASCVD. In the emergency department it is important to remember this disease as part of the differential diagnosis of abdominal ot back pain. The pain is often described as sharp or tearing and may be first appreciated as a change in the usual back complaints suffered by the patient. But it is sometimes mild and ill-defined at first and may escape notice. The abdomen should always be examined in a patient with complaints of back pain. Midline abdominal tenderness, a palpable pulsatile mass or bruit may be appreciated. The femoral pulses should be palpated. Check for hypertension. In suspected renal colic make an effort to prove the diagnosis as soon as possible. If the urine is not positive for blood be especially suspicious that the diagnosis is a symptomatic abdominal aortic aneurysm. In the patient with abdominal complaints it is always important to make a diagnosis and rule out an aneurysm. If there is a suspicion of an abdominal aortic aneurysm first consider whether the patient is symptomatic or asymptomatic for the aneurysm. It the patient is asymptomatic a a vascular workup is ordered urgently. If the patient is symptomatic with either pain, pulsatile mass or bruit an urgent surgical consultation is made with the intention of resecting the aneurysm before it leaks. If the patient shows any signs of hypotension or shock even transiently the patient must go directly to the operating room. Type and Cross for whole blood, packed cells and fresh frozen plasma. Insert large bore iv cannulas and monitor the Blood Pressure. For those who do not require immediate surgery there are some diagnostic tests available in the diagnosis of abdominal aortic aneurysm. Abdominal Flat Plate, especially the lateral, can show eggshell calcifications present in the aneurysm wall, blurring the psoas margin. The psoas muscles are two triangular muscles on either side of the spine. Their edges are visible if there is no fluid in the retroperitoneal space which is where the aorta is located. An IVP is one way to clinch the diagnosis of a cause of renal colic. An abdominal sonogram is a non-invasive way to check the diameter of the abdominal aorta. A CT Scan preferably with IV contrast will show an aneurysm and give information on the integrity of its wall and whether it is leaking. With contrast it will also give the status of the renal arteries which are two branches of the aorta and can become damaged by the aneurysm. Remember these tests can not be done if the patient is at any time hypotensive. The patients next stop is the operating room. In summary abdominal aortic aneurysm will present with pain, pulsatile mass or bruit. It may mimic back pain, renal colic, a slipped disk, diverticulitis, and many other common conditions. In many cases the only thing that protects the patient is the high index of suspicion for the condition kept by the Health Care Provider. A patient with a TRIPLE A and hypotension has a leaking aneurysm until proven otherwise, and must go to the OR as soon as possible without further studies. Do not pass go, do not collect $200. A 50 year old with presumed renal colic, or lumbosacral pain may have a leaking abdominal aortic aneurysm. Remember to include it in the differential diagnosis, the list of possible causes of abdominal or back pain.