HPI:. C.B, a former heavy smoking 69 . yo. M with a h/o hypertension and COPD presents to the ED with sudden onset abdominal, lower back and R flank pain that started 45 min ago while at home watching TV. He also c/o feeling ‘dizzy’ and some nausea at the time. He denies LOC, chest pain, dyspn.... ID: 209203
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Abrupt Abdominal Pain
Slide2HPI:
C.B, a former heavy smoking 69 yo M with a h/o hypertension and COPD presents to the ED with sudden onset abdominal, lower back and R flank pain that started 45 min ago while at home watching TV. He also c/o feeling ‘dizzy’ and some nausea at the time. He denies LOC, chest pain, dyspnea, vomiting, difficulty urinating or blood in his stool. He has not ever had a pain like this before. The pain was a 9/10 initially, but is about a 6/10 after taking some Tylenol at home. His dizziness and nausea are improved at this time.
Slide3ROS:
HEENT
: denies headache, visual changes
CV: no chest pain
Resp
: denies dyspnea, chronic cough
GI: Midline,
peri
-umbilical abdominal pain, nausea w/ pain initially, denies vomiting, diarrhea and blood in stool
GU: no dysuria, hematuria
Ext: denies leg pain, Some R flank and lower back pain
Neuro
: no LOC
or weakness
Slide4PMHx
:
COPD, Hypertension, Hyperlipidemia
PSHx
:
appendectomy at age 20, ‘had a normal colonoscopy’ 3 years ago
Medications:
Spiriva,
Metoprolol
and hydralazine, simvastatin, Fish oil and daily multivitamin
SocHx
:
Former 50 year 2 pack/day smoking history, has been smoke free for 6 months
Moderate alcohol use
Denies recreational drugs
Married, retired truck driver
FamHx
:
Mother – had hypertension
Father – depression
Brother – hypertension and ‘some surgery for an aneurysm’
Slide5Physical Exam
Gen: mild distress
HEENT: NCAT, PERRL, EOMI
CV: RRR, no r/m/g, 2+ radial and dorsal
pedis
pulses
Pulm
: CTA, regular respirations
Abd
: mild
peri
-umbilical tenderness to palpation, pulsatile mass
Ext: normal strength, no CVA tenderness
Skin: no rashes or lesions
Neuro
: A&Ox3, no focal
neuro
deficits
Slide6Differential Diagnosis?
Slide7Perforated viscusPancreatitisAbdominal Aortic Aneurysm (AAA)Urinary CalculiBowel obstructionMusculoskeletal pain
DDx
:
Slide8What would you order next?
Slide9Labs
Vitals
Urine
Hemoccult
CBC
Coagulation
studies
CMP
Lipase and amylase
Imaging
Plain radiography
Abdominal Ultrasound
Abdominal CT w/ and w/o
contrast if stable
Slide10Results
LabsVitals – 100/60 115 37.5 97% on RAUrine – normalHemoccult - negativeCBC 14 8.0 200PT/INR and PTT all normalCMP - 140/ 4.0/ 100/ 24/ 15/ 1.0 / 95Lipase 25, Amylase 50, ALT 25, AST 35
Slide11Bedside Abdominal Ultrasound
Slide12Imaging: Bedside US
Slide13Imaging: Bedside US
http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htm
Slide14Abdominal CT
http://www.medscape.com/content/2004/00/47/08/470838/470838_fig.html
Slide15Diagnosis?
Slide16Abdominal Aortic Aneurysm (AAA)
Bedside Abdominal US shows AAA 6.0 cm in diameter
Confirmed with Abdominal CT with contrast
Slide17Treatment
C.B. is started on IVFs, given 02 by nasal cannula and vascular surgery is consulted
Because of the sudden onset of pain, size of aneurysm, hypotension and feeling ‘dizzy’, there is concern C.B.’s AAA may be rupturing.
He is admitted to vascular surgery for stabilization and urgent AAA repair.
Slide18Abdominal Aortic Aneurysm
Slide19Presentation
Flank, back or abdominal pain
severe and abrupt onset, 50% describe pain as a ripping or tearing
GI bleeding
Syncope (10%)
Extremity ischemia from embolization of a thrombus
Shock: hemorrhagic
Sudden death
Slide20Atypical presentations may complicate the diagnosis:
Flank, groin or isolated quadrants of abdominal pain
Nausea, vomiting
Bladder pain
Hip pain
Tenesmus
Slide21Diagnosis
Physical Exam:
Palpable abdominal mass (only present in 2%)
Tender abdomen
Hypotension
Decreased femoral pulses
Look for
peri
-umbilical
ecchymosis (Cullen sign) or flank ecchymosis (Grey Turner sign
), which indicate acute rupture
Labs:
H&H may not be affected
Slide22Treatment/Management
Symptomatic AAAs require an emergency vascular surgical consult for repair
Concurrent stabilization with IVFs, O2 and bedside diagnosis with US (>90% sensitive for demonstrating presence and measuring diameter
Classic triad of symptom: abdominal and/or back pain, a pulsatile abdominal mass, and hypotension only occur in ~1/3 of patients with ruptured AAAs.
Non-symptomatic AAAs
Prompt outpatient referral to vascular surgeon and BP control
.
AAAs between 4-5cm in diameter are associated with a 1% per year risk of rupture, monitoring every 6 months with US or CT scans.
Any Aneurysm >5.5cm in diameter should be repaired.
Slide23Gross Pathology - AAA
Slide24Gross Pathology – Ruptured AAA
Slide25Microscopic Images - AAA
A microscopic image of the abdominal aortic aneurysm shows intense inflammatory change and fibrosis in the adventitia (H and E, original magnification ×40).
I
nflammation
Fibrosis
Slide26Inflammatory cells are mainly lymphocytes, plasma cells, and
eosinophils (H and E, original magnification ×400).
Microscopic Images - AAA
Slide27Obliterative
phlebitis is observed (EvG, original magnification ×200)
Microscopic Images - AAA
Slide28Immunostaining
of IgG4 reveals numerous IgG4-positive plasma cells within the lesion (immunostaining of IgG4, original magnification ×400).
Microscopic Images - AAA
Slide29Bedside US
Slide30Bedside US
Slide31Imaging: Plain radiography
http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htm
Slide32CT without IV contrast Ruptured Abdominal Aortic Aneurysman abdominal aortic aneurysm (A) with high density blood (arrows) indicating rupture.
http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htm
Slide33References:
Prince
LA, Johnson GA. Chapter 63. Aneurysms of the Aorta and Major Arteries. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds.
Tintinalli's Emergency Medicine: A Comprehensive Study Guide
. 7th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=6359748. Accessed November 6, 2012
.
Elefteriades
JA, Olin JW,
Halperin
JL. Chapter 106. Diseases of the Aorta. In:
Fuster
V, Walsh RA, Harrington RA, eds.
Hurst's The Heart
. 13th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=7836581. Accessed November 7, 2012
.
Images from
http://
www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htm
Yasushi Matsumoto, Satomi
Kasashima
,
Atsuhiro
Kawashima,
Hisao
Sasaki,
Masamitsu
Endo,
Kengo
Kawakami,
Yoh
Zen,
Yasuni
Nakanuma
, A case of multiple immunoglobulin G4–related
periarteritis
: a tumorous lesion of the coronary artery and abdominal aortic aneurysm, Human Pathology, Volume 39, Issue 6, June 2008, Pages 975-980, ISSN 0046-8177, 10.1016/j.humpath.2007.10.023. (http://www.sciencedirect.com/science/article/pii/S004681770700576X) Keywords: IgG4; Autoimmune pancreatitis; Retroperitoneal fibrosis; Aneurysm; Arteritis
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