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?

• Perforated viscus

• Pancreatitis

• Abdominal Aortic Aneurysm (AAA)

• Urinary Calculi

• Bowel obstruction

• Musculoskeletal pain

DDx:

What would you order next?

• Labso Vitalso Urineo Hemocculto CBC o Coagulation studieso CMPo Lipase and amylase

• Imagingo Plain radiographyo Abdominal Ultrasoundo Abdominal CT w/ and w/o contrast if stable

Results

•Labso Vitals – 100/60 115 37.5 97% on RAoUrine – normaloHemoccult - negativeoCBC 14

8.0 200

o PT/INR and PTT all normaloCMP - 140/ 4.0/ 100/ 24/ 15/ 1.0 / 95o 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 paino 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 repairo Concurrent stabilization with IVFs, O2 and bedside diagnosis with

US (>90% sensitive for demonstrating presence and measuring diameter

o 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 Prompt outpatient referral to vascular surgeon and BP control. o 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.o Any Aneurysm >5.5cm in diameter should be repaired.

Gross Pathology - AAA

Gross Pathology – Ruptured AAA

Microscopic 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).

Inflammation

Fibrosis

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).

Microscopic Images - AAA

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 Aneurysman 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. 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.

2. 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.

3. Images from http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htm

4. 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