Abdominal aortic aneurysm

Background

• Infrarenal diameter >3cm or >50% increase in size of diameter
• Rupture Risk
  • <4cm: low risk for rupture
  • 4-5cm: 5 year risk 3-12%
  • >5cm: 25-41%
  • Rupture poss at any size, most commonly >5cm

Risk Factors

1. Age
   1. Prevalence is negligible in age < 50 yrs
2. Smoking
   1. Risk factor most strongly assoc with AAA
   2. Also promotes the rate of aneurysm growth
3. Family history
4. HTN

Diagnosis

• Triad: pain + hypotension + pulsatile mass
  • Pain often described as sudden, severe, radiating to back
• Syncope (10%)
• Pain + AAA = rupture until proven otherwise
• Acute abdomen + hypotension = possible rupture

Workup

• Ultrasound
  • ~100% sensitive for increased diameter
  • Cannot reliably visualize rupture
• CT
  • ~100% sensitive for incr diameter and rupture
  • IV contrast is preferred but not essential

Differential Diagnosis

Lower Back Pain

• Spine related
  • Acute ligamentous injury
  • Acute muscle strain
  • Disk herniation (Sciatica)
  • Degenerative joint disease
  • Spondylolithesis
  • Epidural compression syndromes
    • Spinal cord compression (non-traumatic)
    • Cauda equina syndrome
    • Conus medullaris syndrome
    • Epidural abscess (spinal)
    • Epidural hematoma (spinal)
  • Thoracic and lumbar fractures and dislocations
  • Cancer metastasis
  • Spinal stenosis
  • Transverse myelitis
  • Vertebral osteomyelitis
  • Ankylosing spondylitis
  • Spondylolisthesis
  • Discitis
  • Spinal Infarct
• Renal disease
  • Kidney stone
  • Pyelonephritis
  • Nephrolithiasis
• Intra-abdominal
  • Abdominal aortic aneurysm
  • Ulcer perforation
  • Retrocecal appendicitis
  • Large bowel obstruction
  • Pancreatitis
• Pelvic disease
  • PID
• Other
  • Retroperitoneal hemorrhage/mass
  • Meningitis

Diffuse Abdominal pain

• Abdominal aortic aneurysm
  • Aortocaval fistula
• Acute gastroenteritis
• Aortoenteric fisulta
• Appendicitis (early)
• Bowel obstruction
  • Large bowel obstruction
    • Ogilvie's syndrome
  • Small bowel obstruction
  • Malignant bowel obstruction
• Bowel perforation
• Diabetic ketoacidosis
• Gastroparesis
• Hernia
• Hypercalcemia
• Inflammatory bowel disease
• Mesenteric ischemia
  • Mesenteric vein thrombosis
• Pancreatitis
• Peritonitis
• Sickle cell crisis
• Spontaneous bacterial peritonitis
• Volvulus

Epigastric Pain

• Gastroesophageal reflux disease (GERD)
• Peptic ulcer disease with or without perforation
  • Zollinger-Ellison syndrome
• Gastritis
• Pancreatitis
• Gallbladder disease
  • Acute cholecystitis
  • Cholangitis
  • Symptomatic cholelithiasis
  • Acalculous cholecystitis
• Myocardial Ischemia
• Splenic Infarctionenlargement/rupture/aneurysm
• Pericarditis/Myocarditis
• Aortic dissection
• Hepatitis
• Pyelonephritis
• Pneumonia
• Pyogenic liver abscess
• Fitz-Hugh-Curtis Syndrome
• Hepatomegaly due to CHF
• Bowel obstruction
• SMA syndrome
• Pulmonary embolism
• Bezoar
• Ingested foreign body

Treatment

Rupture

1. Do not waste time in ED trying to "stabilize" pt
2. Immediate surgery consultation/ go to OR
3. Crossmatch 6 units of pRBC
4. Pain control (avoid hypotension)
5. BP control
   1. Controversial
      1. Too little (ischemia), too much (increased bleeding)
         1. Consider allowing for permissive hypotension (SBP 80-100) in conscious pt
      2. Pressors
         1. Norepi 0.05mcg/kg/min IV; titrate by 0.02mcg/kg/min q5min
         2. Phenylephrine 100-180mcg/min; titrate by 25mcg/min q10min
         3. Dopamine 5mcg/kg/min; titrate by 5mcg/kg/min q10min

Asymptomatic

• Prompt vascular surgery outpatient follow-up appt

Source

• Tintinalli
• UpToDate
• Rosen's