Abrupt Abdominal Pain
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, 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.
ROS:
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
PMHx: 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’
Physical 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
Differential Diagnosis?
DDx:
• Perforated viscus
• Pancreatitis
• Abdominal Aortic Aneurysm (AAA)
• Urinary Calculi
• Bowel obstruction
• Musculoskeletal pain
What would you order next?
• Labs
o
o
o
o
o
o
o
Vitals
Urine
Hemoccult
CBC
Coagulation studies
CMP
Lipase and amylase
• Imaging
o Plain radiography
o Abdominal Ultrasound
o Abdominal CT w/ and w/o contrast if stable
Results
• Labs
o Vitals – 100/60 115 37.5 97% on RA
o Urine – normal
o Hemoccult - negative
o CBC
14
8.0
200
o PT/INR and PTT all normal
o CMP - 140/ 4.0/ 100/ 24/ 15/ 1.0 / 95
o Lipase 25, Amylase 50, ALT 25, AST 35
Bedside Abdominal Ultrasound
Imaging: Bedside US
Imaging: Bedside US
http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htm
Abdominal CT
http://www.medscape.com/content/2004/00/47/08/470838/470838_fig.html
Diagnosis?
Abdominal Aortic Aneurysm (AAA)
• Bedside Abdominal US shows AAA 6.0 cm in
•
diameter
Confirmed with Abdominal CT with contrast
Treatment
• 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.
Abdominal Aortic Aneurysm
Presentation
•
Flank, back or abdominal pain
o
•
•
•
•
•
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
Atypical presentations may
complicate the diagnosis:
•
•
•
•
•
Flank, groin or isolated quadrants of
abdominal pain
Nausea, vomiting
Bladder pain
Hip pain
Tenesmus
Diagnosis
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
•
•
•
•
•
Treatment/Management
•
Symptomatic AAAs require an emergency vascular
surgical consult for repair
o
o
•
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
o
o
o
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.
Gross Pathology - AAA
Gross Pathology –
Ruptured AAA
Microscopic Images - AAA
Fibrosis
Inflammation
A microscopic image of the abdominal aortic aneurysm shows intense inflammatory change and
fibrosis in the adventitia (H and E, original magnification ×40).
Microscopic Images - AAA
Inflammatory cells are mainly lymphocytes, plasma cells, and eosinophils (H and E, original
magnification ×400).
Microscopic Images - AAA
Obliterative phlebitis is observed (EvG, original magnification ×200)
Microscopic Images - AAA
Immunostaining of IgG4 reveals numerous IgG4-positive plasma cells within the lesion
(immunostaining of IgG4, original magnification ×400).
Bedside US
Bedside US
Imaging: Plain radiography
http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htm
CT without IV contrast Ruptured Abdominal
Aortic Aneurysm
an abdominal aortic aneurysm (A) with high density blood (arrows) indicating rupture.
http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htm
References:
1.
2.
3.
4.
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