Abdominal Aortic Aneurysm - Quick Consult |
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Last Updated / Reviewed: June 2022
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Definition
Pathophysiology
Key History
Key Physical Exam
Risk Factors for AAA
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment
Abdominal aortic aneurysm, also written as AAA and often pronounced 'triple-A',
is a localized dilatation of the abdominal aorta that exceeds the normal aortic
diameter by more than 50%. The normal diameter of the infrarenal aorta is 2 cm.
AAA is caused by a degenerative process of the aortic wall, however the exact etiology
remains unknown. It is most commonly located below the kidneys (infrarenally; 90%);
other possible locations are above or at the level of the kidneys (suprarenal and
pararenal). The aneurysm can extend to include one or both of the iliac arteries.
An aortic aneurysm may also occur in the thorax.
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The signs and symptoms of an AAA reflect the anatomy of the normal aorta. A review
of these anatomical factors can sometimes assist in making the diagnosis.
- The aorta enters the abdomen at the level of the twelfth acute vertebra and
bifurcates
into the common iliac arteries at the level of the umbilicus.
- The aorta is retroperitoneal throughout its course in the abdomen and normally does
not extend to the right of the midline of the abdomen. If the examiner detects aorta
to the right of the midline, this may represent an aortic aneurysm.
- Various portions of the gastrointestinal tract, venous channels, osseous structures,
ureters, nerves, and nerve roots are close to the aorta and may be involved in the
pathophysiology and symptoms of an AAA.
- The aorta also gives off many branches while in the abdomen: the renal, superior
mesenteric, inferior mesenteric, celiac, and spinal radicular arteries. Involvement
of these arteries is responsible for the development of certain unusual or atypical
neurologic and ischemic signs and symptoms associated with AAA.
- In over 95% of cases, abdominal aneurysms arise below the origins of the renal
arteries.
- The normal infrarenal aorta averages approximately 2.0 cm in diameter.
- The most widely used definition of an AAA is an aorta that is dilated at least 1.5
times that of the adjacent intact aorta, or any abdominal aorta with a diameter
of 3.0 cm or greater.
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- Abdominal pain with shock
- Abdominal pain with syncope
- Pain in the:
- Pain is acute or sudden in onset
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- Pain may be severe and constant
- Pain may radiate to chest, thigh, inguinal area or scrotum
- Shock (may be absent if rupture is contained)
- Flank pain or radiation to the flank is common, often mistaken for renal
colic
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- Pulsatile mass
- Abdominal tenderness
- Classic triad of: mass, pain, hypotension occurs in 30-40% of
cases
- Abdominal bruit
- Decreased femoral pulses
- Decreased urine output
- Back pain
- Hematuria
- A pulsation to the right of the midline of the abdomen. A tortuous or
prominent
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aorta generally does not present to the right of the midline
- A left lower quadrant abdominal mass with abdominal tenderness and
distention (AAA
can rupture into LLQ)
- Livedo reticularis: one or more cool painful cyanotic toes and palpable
pedal pulses
(i.e., emboli to the toes)
- Aortoenteric fistula (AEF): Rupture of an AAA into the gastrointestinal
tract
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- Age > 65
- Male (4:1 male:female)
- 1st degree relative w/ AAA
- Prior AAA or femoral or popliteal aneurysm
- Occlusive peripheral vascular disease
- HTN
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- COPD
- Smoking
- Connective tissue disorder
- Ehlers Danlos Syndrome
- Marfan's Syndrome
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Gastrointestinal |
Genitourinary
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Cardiovascular |
- Appendiceal neoplasm
- Appendicitis
- Cecal diverticulitis
- Cholecystitis
- Cholelithiasis
- Constipation
- Crohn's disease
- Diverticulitis
- Gastroenteritis
- GERD
- GI Bleed
- Hepatitis
- Intestinal obstruction
- Irritable bowel syndrome
- Meckel’s diverticulitis
- Mesenteric adenitis
- Mesenteric ischemia
- Omental torsion
- Pancreatitis
- Peptic ulcer disease
- Perforated ulcer
- Peritonitis
- Small bowel obstruction
- Typhlitis
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Gynecological
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Other
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- Dysmenorrhea
- Ectopic pregnancy [QC]
- Endometriosis
- Menorrhagia
- Ovarian torsion
- PID
- Ruptured cyst (Mittelschmerz)
- Tubal ovarian abscess
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- Diabetes ketoacidosis
- Hemolytic Uremic
Syndromes
- Herpes zoster
- Henoch Schoenlein purpura
- Pneumonia
- Sickle cell crisis
- Streptococcal pharyngitis
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Text / literature information and recommendations include:
- Ultrasonography – 100% sensitive in detecting AAAs provided a good study can be
obtained. Primary role is to screen patients at risk quickly in the emergency
department.
Accomplished at bedside, operator dependent, but the aorta is sometimes not well
visualized. Note: cannot be used to determine if the AAA has ruptured. Rupture can
be confirmed only if free intraperitoneal or retroperitoneal blood is seen
(identifies
leakage only 4% of the time).
- CT – 100% accurate determining presence of AAA. Study takes more time, and is
appropriate
only in hemodynamically stable patients. CT scan is more sensitive in detecting
retroperitoneal hemorrhage associated with aneurysm rupture – reported sensitivity
ranges from 77-100%. Does not accurately identify aortoenteric or venous fistula,
inflammatory aneurysms or infections.
- Helical CT & CTA - Dual-slice helical CT correlates well with surgical findings
in measuring the proximal and distal extent of the aneurysm. CT and CT angiography
are not only less invasive than conventional aortography but also allow for more
rapid scanning times and evaluation of the rest of the abdomen. Again, appropriate
only in hemodynamically stable patients.
- MRI - MRI with MRA has 100 percent sensitivity in detecting aneurysms, and
successfully
identifies the proximal and distal extent of the aneurysms, the number and origins
of renal arteries, and the presence of inflammation. Again, appropriate only in
hemodynamically stable patients.
- KUB – reveals aortic calcification 60% of the time
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- Only 30% of patients present with the classic triad of abdominal pain, a palpable
mass, and hypotension.
- Rupture of an AAA usually occurs into the retroperitoneum, where hemorrhage may
be temporarily limited by clotting and tamponade at the rupture site.
- Of patients with ruptures, 10% to 30% have free intraperitoneal rupture, which is
often rapidly fatal. Occasionally, rupture occurs into the gastrointestinal tract
or the inferior vena cava.
- A pulsatile mass may not be palpable in up to 50% of patients with a ruptured AAA.
- Studies have shown that among patients older than age 65 referred to a urologist
for renal colic, 10% actually have an AAA.
- AAAs typically rupture into the retroperitoneal space. The second most common site
of rupture is the left lower quadrant. Studies demonstrate that 12% of AAAs are
diagnosed initially as diverticulitis.
- Consider the diagnosis in every older patient with abdominal, back, or flank pain.
- A long duration of symptoms does NOT preclude the diagnosis of ruptured AAA.
- Hypotension is present in only one-half to two-thirds of patients with rupture and
is often a late finding.
- Any size aneurysm can rupture, but it is more likely in aneurysms > 5 cm in
diameter.
- There is virtually no risk of causing aneurysm rupture by abdominal palpation.
- Blue Toe syndrome is highly suggestive of a proximal source of emboli and an AAA
may be the source.
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Common text / literature recommendations include:
The appropriate degree of preoperative volume resuscitation is controversial. In
the prehospital setting and in the emergency department before the availability
of a surgeon and the operating room, the blood pressure should be raised with crystalloid
or blood products to a level that maintains adequate cerebral and myocardial perfusion.
- Two large bore IVs should be placed
- Type and cross-matched for packed red cell transfusion
- Immediate surgical repair; endovascular repair may be possible for patients at poor
surgical risk
- If hypertensive: Esmolol, labetalol, or nitroprusside are used to reduce pressure
on the aortic wall
- A patient with a ruptured AAA should be moved as expeditiously as possible to the
operating room. Precious time should not be spent with prolonged resuscitation or
diagnostic imaging.
- Incidental diagnosis of AAA in the Emergency Department - If the AAA is small
and felt to be asymptomatic, the patient will need mandatory, time-specific
instructions for follow up. Document these instructions/expectations in the medical
record and stress compliance with follow up on discharge. Current literature
supports close monitoring of aneurysms < 5.5 cm and elective surgical repair for
aneurysms ≥ 5.5 cm or for an aneurysm that has increased in size by 0.5 cm in
the past 6 months dependent on surgical risk factors.
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