Case Details

General Medicine General Surgery Surgical Gastroenterology Radiology

Indian Doctors Network posted a case

over 1 year ago

A PULSATILE MASS IN THE ABDOMEN

Courtesy: 100 cases in surgery

History
A 68-year-old man presents to the emergency department with a 1h history of pain in the left side of his abdomen. The pain started suddenly while he was getting up from a chair.It became constant and radiated through to his back. His past medical history includes hypertension and stable angina. He lives with his wife and is normally independent.

Examination
The patient is pale, sweaty and clammy. His pulse is 100/min and the blood pressure is 90/50 mmHg. Heart sounds are normal and the chest is clear. Examination of the abdomen reveals a large tender mass in the epigastrium. The mass is both pulsatile and expansile.

The peripheral pulses are present and equal on both sides. There is no neurological deficit.

Questions
• What is the most likely diagnosis?
• What is required in the immediate management of this patient?
• What is the prognosis?

ANSWER
The most likely diagnosis is a ruptured abdominal aortic aneurysm. An aortic aneurysm is defined as an increase in aortic diameter by greater than 50 per cent of normal (3 cm).The aneurysm diameter increases exponentially by approximately 10 per cent per year.

As the aneurysm expands, so does the risk of rupture:
Aneurysm size:
• 5.0–5.9 cm, 25 per cent 5-year risk of rupture
• 6.0–6.9 cm, 35 per cent 5-year risk of rupture
• more than 7 cm, 75 per cent 5-year risk of rupture.

Aneurysm rupture can present with abdominal pain radiating to the back, groin or iliac fossae. An expansile mass is not always detectable and other conditions, such as acute pancreatitis or mesenteric infarction, should always be considered. Intravenous access should be established quickly with two large-bore cannulae. Ten units of crossmatched blood, fresh-frozen plasma and platelets should be requested. The bladder should be catheterized and an electrocardiogram (ECG) obtained. It is important not to resuscitate the patient aggressively as a high blood pressure may cause a second fatal bleed. The patient should be taken immediately to theatre and prepared for surgery. A vascular clamp is placed onto the aorta above the leak and a graft used to replace the aneurysmal segment. Some centres now practise endovascular stenting of ruptured aneurysms in a patient stable enough to undergo computerized tomography (CT) scanning.
The mortality from a ruptured aneurysm is high, with haemorrhage, multi-organ failure,myocardial infarction and cerebrovascular accidents accounting for most deaths.



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