Patient with a Pulsatile

Abdominal Mass
Rohail Gul
2017-068
 Case 1
• A 62 year old man comes for his routine physical
examination during which you find an
asymptomatic pulsatile abdominal mass.
• His past medical history is significant for
hypertension and stable angina.
• He has a history of cigarette smoking (2 packs per
week)
• His current medications include aspirin, a β -
blocker, and nitrates.
• The patient describes himself as an active man who
is retired and plays golf twice a week.
• On examination BP 130/80, pulse 86 bpm, RR 20 b/min, temp 37°C.
• The carotid pulses and upper extremity pulses are found to be normal.
• The abdomen
• Inspection: flat abdomen with a central pulsating mass in the just above
the umbilicus. Overlying skin shows no erythema, scar marks or skin
changes.
• Palpation: non-tender with a prominent Expansile pulsation.
• Ausculation: Bruit is heard. Bowel sounds are audible.
• Pulses in the femoral and popliteal regions are easily palpated and appear
more prominent than usual.
 CASE 1
• Formulate a differential diagnosis
• What is your most likely diagnosis?
• What investigations can you perform to
confirm your diagnosis?
• What are the potential complications of this
disease?
• What is the best treatment for this disease?
 Differential Diagnosis
• Abdominal Aortic Aneurysm
• Tortuous Aorta
• CA head of pancreas
Lying Adjacent to
• Pancreatic pseudo cyst the normal aorta
• Gastric CA that might transmit
aortic pulsation
• Colonic CA
• Lymphoma
• An Abscess
Asymtomatic Abdominal Aortic
Aneurysm
 Aneurysm- General
• Dilatations of localised segments of the arterial system are
called aneurysms. (greater than 50% of its normal diameter)
• Normal aorta=1.5cm in females and 1.7cm in males
• Enlargement of the diameter of the abdominal aorta to 3 cm
or more fits the definition.
• 90% are infrarenal
• A diameter >5.5cm is considered a large aneurysm.
 Classification
• They can be:
1. True aneurysms, containing the three layers of the arterial wall (intima,
media, adventitia) in the aneurysm sac
2. false aneurysms, having a single layer of fibrous tissue as the wall of the
sac, e.g. aneurysm following trauma. Blood leaks from the artery and is
surrounded by connective tissue while maintaining communication with
artery so its pulsatile and expansile.

• Aneurysms can also be grouped according to their

a) shape (fusiform, saccular, dissecting)
b) their aetiology (atheromatous, traumatic, syphilitic, mycotic, etc.). The
term mycotic is a misnomer because, although it indicates infection as a
causal element in the formation of the aneurysm, this is due to bacteria,
not fungi.
 Pathophysiology
• Change in matrix. More collagen and less elastin in the abdominal aorta.
• Excessive connective tissue degradation
• Loss of smooth muscle cells from the vascular wall.
• The 2 most important causes are HTN and atherosclerosis.
• Inadequate or abnormal connective tissue synthesis (Marfan Syndrome, EDS)
• Other conditions that weaken vessel walls include trauma, vasculitis, infections.
 Aetiology
• Age >65
• Gender: Male
• Genetics
• Smoking
• HTN
• Atherosclerosis
• COPD
• Ehlers Danlos Syndrome (collagen defect)
• Marfan Syndrome (fibrillin defect)
• Syphilis
• Mycotic; bacterial rather than fungal
 Investigations
• X Ray
• CT scan
• Ultrasound
• Duplex scan
• MRA
• DSA
X-ray
Ultrasound showing
a patient with an
abdominal aortic
aneurysm.
Ultrasonogram of an aortic aneurysm showing the large clot-filled sac with a small central lumen
(transverse and longitudinal scans).
 An abdominal
computed
tomography (CT)
scan revealed a
thrombosed infra-
renal aneurysm
with a maximum
transverse
diameter of 10.5
cm
Contrast-enhanced CT scan with 3-
dimensional reconstruction demonstrating
a 5.6-cm infrarenal abdominal aortic
aneurysm.
CT Angiograms (CTAs)
MRA
DSA
 Treatment
Asymptomatic aneurysm <55mm is
conservatively managed:
• Quit smoking
• Eating a balanced diet
• Ensuring you maintain a healthy weight
• Taking regular exercise
• Regular CT scan or ultrasound.
Medical:
• Antihypertensives
• Antihyperlipidemics
• Doxycycline is being investigated as an agent
that may retard the aneurysm growth, based
on its MMP-inhibiting properties.
 Case 2
• A 60 year old male, known hypertensive and smoker
presented with abdominal pain and back pain for the past
two months.
• The pain originates from epigastric region, was not
continuous, severe intensity, radiates to back and flank.
• The pain got relieved with analgesics. There were occasional
episodes of vomiting as well. There was no associated fever.
The vomitus consisted of food particles taken earlier. The
patient was treated initially by local doctor and MRI of spine
was done which was unremarkable.
• His medical history is of mild HTN and he has a 100-pack-year
tobacco history.
• His BP was 110/80 , pulse 82, RR 20, temp 37°C
• O/E Of the abdomen
• Inspection: a pulsatile mass In the epigastric region.
Overlying skin shows no changes
• Palpation: it is 7cm by 6cm in mid epigastric region. Upper
limit is the xiphoid process while the lower limit is the
umbilicus. Its non tender on palpation.
• Auscultation: bruit is heard. Bowel sounds are audible.
• Peripheral pulses were palpable.
 CASE 2
• Formulate a differential diagnosis

• What is your most likely diagnosis?

• What investigations can you perform to confirm your

diagnosis?

• What are the potential complications of this disease?

• What is the best treatment for this disease?

Symptomatic AAA
 Clinical Features
• All aneurysms can cause symptoms, as a result of
expansion, thrombosis, rupture or the release of
emboli.
• The symptoms relate to the vessel affected and the
tissues it supplies.
• Most aneurysms of clinical significance can be
palpated and, typically, an expansile pulsation is
felt. Transmitted pulsation through a mass lesion,
cyst or abscess lying adjacent to a large artery may
be mistaken for aneurysmal pulsation.
 Clinical Presentation
Clinical Features
Intrinsic Features Extrinsic Features
Swelling with expansile Pressure on the surrounding • Asymptomatic
pulsation structures like veins can
cause edema
Swelling diminishes if Pressure on trachea and
• Symptomatic- if
pressure is applied proximal esophagus can cause complications
to the swelling dyspnea and dysphagia develop:
Palpable thrill Bones may also be eroded I. Rupture
II. Thrombosis
Briut may be audible Pressure on vertebra may
cause back ache
III. Embolization
IV. Pressure symptoms
3% of aneurysms cause pain V. Infection
Distal pulses may be diminished
from embolization of because of inflammation
intraluminal thrombus.
Computerised tomogram of
the abdomen showing an
aortic aneurysm. Blood
flowing through the
thrombus-containing sac is
enhanced with contrast
agent and appears white.
Indications for Operation
 Relative Contraindications
• Recent Myocadial infarction
• Congestive heart failure
• Coronary artery Disease
• Life expectancy <2 years
• Incapacitating Neurological deficit after stroke
 Investigations before Elective Surgery
• CBC
• Electrolytes
• Liver function tests
• coagulation tests
• blood lipid estimation
• Blood Crossmatch
• Electrocardiography and cardiac assessment by echocardiography or isotope
ventriculography are useful.
• Chest radiography and pulmonary function tests should also be carried out.
• The morphology of the aneurysm is best assessed by CT scan or magnetic resonance
imaging.
• Although a digital subtraction or magnetic resonance angiogram may be useful in
delineating any associated arterial occlusive disease,it should be appreciated that this
does not permit an assessment of aneurysm diameter because the sac is usually filled
with circumferential clot leading to a falsely narrow angiographic appearance
 Surgical Management
• Once the decision is made to repair the
aneurysm, there are several operative
methods:
1. Open surgical repair
2. Simple Endovascular Stent-Graft repair
 Open Surgery
• This involves generally a large incision in the abdomen
with exposure of the aorta as it lies on the vertebrae
(spine), moving all the bowel out of the way.
• The aorta is then clamped, as are the arteries to the legs
below the aneurysm, allowing the aorta to be opened,
and a “new” synthetic aorta (graft) to be sewn to normal
artery above and below the aneurysm.
• The aneurysm is then “closed over” the graft to protect it
from coming into contact with the bowel.
Operative appearance
of a huge, non-
ruptured infrarenal
abdominal aortic
aneurysm.
(a) Aneurysm sac opened. Note that the posterior wall of the aorta immediately above and below the
sac is not divided. A Dacron tube graft is laid in place within the sac ready for suture.
(b) Graft sutured in place and vascular clamps removed.
Aortic graft. Transverse scan showing the graft in the
dilated aortic bed.
 Complication
• Arrhythmias, Myocardial ischemia or infarction may
occur
• Intra-operative hemorrhage
• Aortic Cross-Clamping Shock
• Renal Insufficiency
• Low extremity ischemia
• Micro Emboli
• Gastro intestinal Complications
• Paraplegia
• Sexual Dysfunction
 Endovascular procedure

• The aorta is accessed via the femoral arteries, which

are exposed surgically.
• Under radiological control, a delivery system is guided
up into the aorta and an endovascular prosthesis (often
termed a ‘stent graft’) placed within the aortic sac.
• The prosthesis is made from Dacron or PTFE with an
integral metallic stent for support and to allow firm
attachment to the vessels above and below the sac.
Simple
Endovascular aneurysm repair
grafts in clinical use today
 Complications
• Early: branch occlusion, distal embolization,
graft thrombosis, and arterial injury
• Arterial dissection
• Graft migration
• Endoleak
EVAR
 Case 3
• A 45 year old male patient presented with
shock and abdominal mass to emergency
Department. His attendant gives a history of
onset of sharp abdominal pain that radiated
to the back before he collapsed. The patient
is a known hypertensive, and a smoker for
the past 20 years.
• O/E the patients vital signs showed hypotension and , tachycardia.
• Abdomen: inspection: distended abdomen with a large central pulsatile
mass between the xiphoid and the umbilicus. Overlying skin shows
hemmorage.
• On palpation: Tender, pulsatile expansile mass is felt in the epigastric
region About 9cm by 5cm
• Auscultation: no bruit heard. Bowel sounds were reduced.
• His right lower limb pulses were absent .
• What is your most likely diagnosis?
• How would you manage this patient in
emergency department?
• What investigations can you perform to
confirm your diagnosis? What other
investigations will you do?
• What is the best treatment for this disease?
Ruptured abdominal aortic
aneurysm
 Ruptured abdominal aortic aneurysm

• Abdominal aortic aneurysms can rupture

1. Anteriorly: into the peritoneal cavity (20%) Anterior rupture results
in free bleeding into the peritoneal cavity; very few patients reach
hospital alive.
2. Posterolaterally : into the retroperitoneal space (80%). Posterior
rupture on the other hand produces a retroperitoneal haematoma.
• Often a brief period follows when a combination of moderate
hypotension and the resistance of the retroperitoneal tissues arrests
further haemorrhage.
• The patient may remain conscious but in severe pain.
• If no surgery is performed, death is virtually inevitable. Surgery
results in a better than 50% survival rate.
• To achieve the best results, diagnosis and treatment must be rapid.
Ruptured abdominal aortic aneurysm
 Ruptured aortic aneurysm

• Medical emergency

• Triade: abdominal/back pain, hypotension,

pulsatile abdominal mass.

• CT scan to confirm rupture.

 Emergency Management
• Early diagnosis is the key to good management.
• On examination : A tender, pulsatile mass is usually palpable in the abdomen of a
hypotensive patient. If there is doubt about rupture a CT scan is of more help than USG.
In practice, most diagnoses are reached on clinical grounds alone, without imaging.
• Immediate resuscitation (oxygen, intravenous replacement therapy, central line)
• Maintain systolic BP , <100mmHg . Elevation into the normo-tensive range may provoke
further uncontrolled haemorrhage.
• Urinary catheter
• Cross match 6 units of blood
• Rapid transfer to operating theatre.
 Computed
tomography
(CT) showed
this ruptured
abdominal
aortic
aneurysm. The
blue arrow
indicates the
aneurysm and
the red arrow
indicates the
free blood in
the abdomen
THANK YOU