Review Question - QID 203297

Any elderly patient with a significant smoking history who presents with chest/abdominal/back pain and hypotension should immediately receive an abdominal emergency medicine bedside ultrasound (EMBU) to assess for ruptured abdominal aortic aneurysm (AAA).

AAA is a local enlargement of the abdominal aorta >3 cm that is commonly observed in elderly patients. Risk factors include smoking, high blood pressure, and other heart or blood vessel diseases. AAA rupture is a true emergency with mortality exceeding 90%. The majority of patients (~70%) do not make it to the hospital alive. Symptoms include vague back, abdominal, or chest pain and are often accompanied by hypotension and hypovolemic shock. If the AAA ruptures in the intraabdominal cavity, death usually results. Retroperitoneal rupture can result in temporary tamponade which can increase survival and allow enough time for surgical intervention to be performed. In cases of retroperitoneal rupture, flank ecchymosis (Grey Turner's sign) may be observed (Figure A). Diagnosis is usually made via ultrasound or contrast enhanced abdominal CT scan. Treatment is immediate volume resuscitation and emergency operative repair.

Upchurch and Schaub review the diagnosis and management of AAA rupture. They state symptomatic aneurysms present with back, abdominal, buttock, groin, testicular, or leg pain and require urgent surgical attention. Rupture of an AAA involves complete loss of aortic wall integrity and is a surgical emergency requiring immediate repair. The mortality rate approaches 90 percent if rupture occurs outside the hospital.

Lyon and Clark review the diagnosis of acute abdominal pain in older patients. They state acute abdominal pain is a common presenting complaint in older patients. Presentation may differ from that of the younger patient and is often complicated by coexistent disease, delays in presentation, and physical and social barriers. The physical examination can be misleadingly benign, even with catastrophic conditions such as abdominal aortic aneurysm rupture and mesenteric ischemia.

Figure A demonstrates flank ecchymosis or Grey Turner's sign which can be observed in retroperitoneal bleeds such as AAA rupture. Figure B demonstrates an EKG with normal sinus rhythm. Illustration A demonstrates periumbilical ecchymosis or Cullen's sign which can also be observed in AAA rupture. Illustration B is an abdominal ultrasound demonstrating a ruptured AAA. Illustration C is a contrast enhanced abdominal CT demonstrating a ruptured AAA.

Incorrect answers:
Answer 1: A non-contrast chest CT, while useful in demonstrating pulmonary pathology, would not be useful in diagnosing a possible AAA rupture. A contrast enhanced abdominal CT would need to be used.
Answer 2: While Troponin/CK MB would most likely be run eventually on this patient, an abdominal EMBU (emergency medicine bedside ultrasound) should be performed first to assess for a possible AAA.
Answer 3: While pancreatitis can present with severe abdominal pain, obtaining an amylase and lipase does not take priority over abdominal EMBU.
Answer 5: While lower lobe pneumonia can present as abdominal pain, obtaining a chest radiograph does not take priority over abdominal EMBU.