Item ~?Mark <?

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An 84-year-old man is brought to the emergency department because of 1 hour of severe

back pain. He also had syncope that lasted <1 minute. Before arriving at the hospital,
he had an episode of gross hematuria, which he has never had before. He also
complains of some shortness of breath. He denies chest pain, cough, nausea, vomiting,
headache, and neck pain. His blood pressure is 72/55 mm Hg and pulse is 11 2/min and
regular. His pulse oximetry shows 92% on room air. His ECG shows sinus tachycardia
with prominent horizontal ST-segment depression in the anterior chest leads. Which of
the following is the most likely diagnosis?

o A. Abdominal aortic aneurysm rupture

o B. Acute mesenteric ischemia
o C. Acute myocardial infarction
0 D. Massive pulmonary embolism
o E. Nephrolithiasis with renal colic

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Item ~?'Mark <] C> 6j ~~ ~ , 0I[AJ
0. ld : 3551 Previous Next Lab Values Notes Calculator Reverse Color Text Zoom

An 84-year-old man is brought to the emergency department because of 1 hour of severe

back pain. He also had syncope that lasted <1 minute. Before arriving at the hospital,
he had an episode of gross hematuria, which he has never had before. He also
complains of some shortness of breath. He denies chest pain, cough, nausea, vomiting,
headache, and neck pain. His blood pressure is 72/55 mm Hg and pulse is 11 2/min and
regular. His pulse oximetry shows 92% on room air. His ECG shows sinus tachycardia
with prominent horizontal ST-segment depression in the anterior chest leads. Which of
the following is the most likely diagnosis?

A Abdominal aortic aneurysm rupture [75%)

B. Acute mesenteric ischemia [3%)
C. Acute myocardial infarction [8%)
D. Massive pulmonary embolism [4%)
C> E. Nephrolithiasis with renal colic [1 0%)

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Explanation: User ld
This patient presents with acute onset of severe back pain, syncope, and hypotension
worrisome for a possible abdominal aortic aneurysm (AAA) rupture. The abdominal aorta
is 1-3 em in diameter in most individuals, and a diameter >3 em at the level of the renal
arteries is considered to be an aneurysm. Unlike thoracic aortic aneurysms, an AAA
involves all aortal layers and does not create an intimal flap or false lumen. An AAA
typically occurs in people aged >60 years and occurs at a higher rate in smokers, men,
and people with a history of coronary artery disease.
Patients typically have few symptoms with AAAs, which are usually incidentally found on
screening ultrasound or CT scan of the abdomen. Physical examination can reveal a
pulsatile abdominal mass at or above the level of the umbilicus. Once the aneurysm
ruptures, only about 50% of the patients survive to come to the hospital. They present
with profound hypotension, abdominal or back pain followed by syncope, and possible
pulsatile mass on examination. An AAA can rupture into the retroperitoneum and create
an aortocaval fistula with the inferior vena cava, leading to venous congestion in
retroperitoneal structures (e.g. , bladder). The fragile and distended veins in the bladder
can rupture and cause gross hematuria (as in this patient).
The symptoms and signs can also mimic other abdominal pathologies, such as renal
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Item ~?'Mark <] C> 6j ~~ ~ , 0I[AJ
0. ld : 3551 Previous Next Lab Values Notes Calculator Reverse Color Text Zoom

Explanation: User ld
This patient presents with acute onset of severe back pain, syncope, and hypotension
worrisome for a possible abdominal aortic aneurysm (AAA) rupture. The abdominal aorta
is 1-3 em in diameter in most individuals, and a diameter >3 em at the level of the renal
arteries is considered to be an aneurysm. Unlike thoracic aortic aneurysms, an AAA
involves all aortal layers and does not create an intimal flap or false lumen. An AAA
typically occurs in people aged >60 years and occurs at a higher rate in smokers, men,
and people with a history of coronary artery disease.
Patients typically have few symptoms with AAAs, which are usually incidentally found on
screening ultrasound or CT scan of the abdomen. Physical examination can reveal a
pulsatile abdominal mass at or above the level of the umbilicus. Once the aneurysm
ruptures, only about 50% of the patients survive to come to the hospital. They present
with profound hypotension, abdominal or back pain followed by syncope, and possible
pulsatile mass on examination. An AAA can rupture into the retroperitoneum and create
an aortocaval fistula with the inferior vena cava, leading to venous congestion in
retroperitoneal structures (e.g. , bladder). The fragile and distended veins in the bladder
can rupture and cause gross hematuria (as in this patient).
The symptoms and signs can also mimic other abdominal pathologies, such as renal
colic, mesenteric ischemia, pancreatitis, diverticulitis, and biliary disease. This patient's
acute onset of symptoms, age, and profound hypotension suggest ruptured AAA, which
must be ruled out before the other etiologies. He should be immediately taken to the
operating room for emergent surgical repair of the ruptured AAA. Mortality with this
condition is approximately 50%, so early recognition and operative intervention is
essential.
(Choice B) Mesenteric ischemia typically presents with pain out of proportion to the
examination and is less likely in this patient given his profound hypotension and back
pain.
(Choice C) Elderly patients with AAA rupture can present with ECG changes indicating
ischemia (e.g., the ST depressions seen in this patient), but profound hypotension and
back pain are more concerning for AAA rupture than acute coronary syndrome.
(Choice 0) Massive pulmonary embolism typically presents with hypotension and
distended neck veins and is less likely in this patient.
(Choice E) Nephrolithiasis can cause gross hematuria, but the hypotension and lack of
flank pain radiating to the groin makes it less likely in this patient.
Educational objective:
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with profound hypotension, abdominal or back pain followed by syncope, and possible
pulsatile mass on examination. An AAA can rupture into the retroperitoneum and create
an aortocaval fistula with the inferior vena cava, leading to venous congestion in
retroperitoneal structures (e.g., bladder). The fragile and distended veins in the bladder
can rupture and cause gross hematuria (as in this patient).

The symptoms and signs can also mimic other abdominal pathologies, such as renal
colic, mesenteric ischemia, pancreatitis, diverticulitis, and biliary disease. This patient's
acute onset of symptoms, age, and profound hypotension suggest ruptured AAA, which
must be ruled out before the other etiologies. He should be immediately taken to the
operating room for emerg ent surgical repair of the ruptured AAA. Mortality with this
condition is approximately 50%, so early recognition and operative intervention is
essential.

(Choice B) Mesenteric ischemia typically presents with pain out of proportion to the
examination and is less likely in this patient given his profound hypotension and back
pain.

(Choice C) Elderly patients with AAA rupture can present with ECG changes indicating
ischemia (e.g. , the ST depressions seen in this patient), but profound hypotension and
back pain are more concerning for AAA rupture than acute coronary syndrome.

(Choice D) Massive pulmonary embolism typically presents with hypotension and

distended neck veins and is less likely in this patient.

(Choice E) Nephrolithiasis can cause gross hematuria, but the hypotension and lack of
flank pain radiating to the groin makes it less likely in this patient.

Educational objective:
Patients who present with acute onset of back pain and profound hypotension should be
evaluated for a presumptive diagnosis of ruptured abdominal aortic aneurysm and
emergently taken to the operating room.

References:
1. Ruptured abdominal aortic aneurysm: a surgical emergency with many
clinical presentations
2. Haemodynamic management in ruptured abdominal aortic aneurysm
3. Hematuria is an indication of rupture of an abdominal aortic aneurysm
into the vena cava.

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