What’s the Diagnosis? By Dr. Austin Redilla

A 60 year old woman with a past medical history of HTN, HLD, and recent TIA now on Aspirin and Eliquis presents to the ED with one month of crampy, intermittent abdominal pain. She describes feeling sharp cramps in the epigastric region which typically last a couple of minutes and then resolve on their own. She cannot recall any exacerbating or relieving factors. She does not have any associated nausea, vomiting, diarrhea, or dysuria. She is currently without pain. On exam, her abdomen is non-tender without any rebound or guarding. POCUS findings are as below. What’s the diagnosis?

Answer: Abdominal Aortic Aneurysm with impending rupture

• The aorta can be visualized with the curvilinear probe and is found lying just anterior to the spine. AAA is defined as an aorta >3cm in diameter; repair is considered with diameter >5cm or in symptomatic patients. Smoking is the greatest risk factor, increasing chances 4x compared to lifetime non-smokers. Other risk factors include family member with AAA, male sex, and age >60¹.
• Physical exam is only 29% sensitive for aortic diameter 3.0 – 3.9cm, 50% for 4.0 – 4.9cm, and 76% for greater than 5.0cm². This patient did have a palpable abdominal pulsation with deep pressure. Tenderness is associated with unstable AAA, though lack of pain does not rule this out.
• Bedside US dramatically increases sensitivity to >90% for diagnosing and measuring AAAs of all sizes³. Measurements should be taken from the outside wall to outside wall in transverse and longitudinal views. This patient’s aorta was measured to be >5cm and had concerning signs of thickened walls.
• CTA is the gold standard for diagnosis and measurement in stable patients. This patient had findings of extension of luminal contrast beyond the expected aortic wall and calcifications, which was concerning for impending rupture⁴. The patient was evaluated by vascular surgery and taken Level 1 to the OR for emergent open aortic repair.

References:

1. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th Edition. Prince, L. Johnson, G. Chapter 60. Page 416. McGraw Hill Professional, 15 Nov. 2023.
2. Lederle FA, Simel DL: The rational clinical examination. Does this patient have abdominal aortic aneurysm? JAMA 281: 77, 1999. [PMID: 9892455]
3. American College of Emergency Physicians: Emergency ultrasound imaging criteria compendium. Ann Emerg Med 48: 487, 2006. [PMID: 16997700]
4. Vu KN, Kaitoukov Y, Morin-Roy F, Kauffmann C, Giroux MF, Thérasse E, Soulez G, Tang A. Rupture signs on computed tomography, treatment, and outcome of abdominal aortic aneurysms. Insights Imaging. 2014 Jun;5(3):281-93. doi: 10.1007/s13244-014-0327-3. Epub 2014 May 1. PMID: 24789068; PMCID: PMC4035490.