Postgrad Med J: first published as 10.1136/pgmj.69.807.6 on 1 January 1993. Downloaded from Postgrad Med J (1993) 69, 6- 11 © The Fellowship of Postgraduate Medicine, 1993 Review Article Atypical manifestations ofruptured abdominal aortic aneurysms A. Banerjee Accident and Emergency Department, East Birmingham Hospital, Bordesley Green East, Birmingham B95ST, UK Introduction The rupture of an abdominal aortic aneurysm is a The majority of published series of ruptured catastrophic event with a uniformly fatal outcome abdominal aortic aneurysms deal with the outcome if untreated. The triad of abdominal and/or back of those submitted to surgery. Untreated cases, pain, a pulsatile abdominal mass, and hypotension, misdiagnoses and delayed diagnoses are generally is said to be diagnostic. However, this triad may not not discussed. Hence the precise extent of these be present in its entirety, or when present may not problems is unclear. be recognized, as one of the components However, data from various sources suggest that predominates. Clinical diagnosis is thus 'not infre- the diagnosis of ruptured abdominal aortic quently missed in the emergency rooms ofeven the aneurysms is difficult and often missed. In a study most prestigious medical centers." of 9.894 autopsies in two Glasgow hospitals,6 41 To add to this, difficulties in diagnosis may arise patients were noted to have died in hospital with owing either to an impalpable aneurysm or to unoperated ruptured abdominal aortic aneurysms. copyright. atypical presentations.2'3 The clinical diagnosis is The diagnostic triad was present in nine. The often difficult and not infrequently missed. Conse- correct diagnosis had been made in 24. In a series of quently, appropriate treatment in the form of 100 ruptured aneurysms admitted to hospital,7 in expeditious laparotomy, rapid control of the prox- 58 cases surgery was delayed. In 42 instances this imal aorta and graft replacement ofthe aneurysmal was due to an incorrect diagnosis. Emergency aorta is not achieved leading to possibly avoidable operation was performed for an incorrect diagnosis mortality. in five cases. The purpose of this report is to discuss less The implications of this are thatjunior staff may http://pmj.bmj.com/ common presentations of ruptured aneurysms of not be prepared to deal with the ruptured aneurysm the abdominal aorta, concentrating on the clinical when encountered and cross-matched blood may aspects. not be available. Of 44 admissions to a hospital with ruptured aneurysms of the abdominal aorta,8 in 15 patients Extent ofthe problem the diagnosis was missed altogether. In another study of 47 patients with ruptured abdominal on September 28, 2021 by guest. Protected The incidence of abdominal aortic aneurysms aortic aneurysm who died in hospital over a 4 year appears to be rising, independent of any increased period, the diagnostic triad was noted in only 19 detection from improved diagnostic techniques.4 In patients.9 Twenty-four patients underwent surgery, the absence of any effective community screening only 16 having had the correct preoperative diag- programme and also because symptomatic aneur- nosis. ysms are treated surgically at an early stage, In a series of 119 patients with ruptured ruptured previously undiagnosed aneurysms con- abdominal aortic aneurysms who reached a hos- tinue to arrive in hospital. Methods to detect pital alive,'0 20 died in the Accident and Emergency aneurysms based on community screening by Department (only five being diagnosed correctly), clinical examination are, in any case, likely to be and 24 died on the ward without surgery (nine inaccurate.5 This implies that rupture is often the being undiagnosed). first clue to the presence of an aneurysm. Of 120 patients with ruptured abdominal aortic aneurysms in one health district," 12 died in hospital from undiagnosed rupture. Of 56 deaths Correspondence: A. Banerjee, F. R.C.S. outside hospital, 27 had been seen before death by a Accepted: 18 June 1992 doctor but the correct diagnosis was not suspected. Postgrad Med J: first published as 10.1136/pgmj.69.807.6 on 1 January 1993. Downloaded from RUPTURED ABDOMINAL AORTIC ANEURYSMS 7 In the above series, failure to consider the correct presentation of abdominal aortic aneurysmal rup- diagnosis and to recognize atypical presentations ture, in association with fistula formation with contributed directly to most of the deaths. It is either the inferior vena cava or the left renal unfortunately not possible to comment on the vein.'8-20 Haematuria in the presence of a symp- relative proportions. Inappropriate orthopaedic, tomatic aneurysm must be considered as being due urological, neurological and medical referrals to the aneurysm until proven otherwise. Systemic resulted in many instances. Commonly recorded circulatory effects ofthe fistula must be sought. The misdiagnoses are enumerated in Table I. haematuria has been attributed to venous conges- tion of the kidney and bladder, and characteris- tically clears promptly with resection of the Urological presentations aneurysm. Urological presentations are not infrequent. Ten per cent of a series of 400 patients with abdominal Neurological presentations aortic aneurysms (intact and ruptured) who under- went surgery for the aneurysm presented with The precise incidence of neurological complica- features suggesting genitourinary disease.12 tions associated with ruptured abdominal aortic Unilateral flank pain, either right- or left-sided, aneurysm is not known. However, they appear to with distal radiation to the genitalia, hip and thigh, be relatively uncommon. A ruptured abdominal is often a presenting feature ofaneurysmal rupture. aortic aneurysm can present as an acute unilateral This may be misdiagnosed as ureteric colic.'3 4 The painful neuropathy affecting the femoral and/or cause of this pain is believed to be irritation of the obturator nerves.2'125 A similar constellation of ureteric pain fibres in the sympathetic plexus by the symptoms and signs has been previously en- retroperitoneal haematoma. This appears to be a countered with patients on anticoagulant therapy relatively common diagnostic problem. In one and in haemophiliacs. The mechanism is that of series of 44 cases of aneurysmal rupture, five were pressure on these nerves by the extraperitoneal noted to have ureteric colic-like presentation.8 In haematoma present in each instance. copyright. another series of 105 patients, 18 presented with The presentation is with severe hip and thigh unilateral loin pain.'5 pain, paraesthesiae and sensory loss of femoral In many cases, the misdiagnosis of ureteric colic nerve distribution (anteromedial thigh), weakness leads to inappropriate intravenous urography, of hip flexion (iliopsoas) and of knee extension with deterioration during, or immediately after, the (quadriceps femoris) and loss of the knee jerk. In procedure (Figure 1). One must be wary ofthe first many reported instances, inappropriate neuro- episode of ureteric colic in the middle aged and logical and orthopaedic investigation has been elderly, and leaking abdominal aortic aneurysm associated with delayed diagnosis. The neuropathy http://pmj.bmj.com/ must be part of the differential diagnosis. In the is reversible with early definitive treatment of the haemodynamically stable patient, ultrasound aneurysm but, if this is delayed, residual assessment is recommended.'6 This can demon- neurological deficit with prominent quadriceps strate both aneurysmal leakage as well as urinary wasting ensues. Intractable sciatica owing to sciatic tract obstruction. Three cases of isolated severe nerve compression by haematoma has also been unilateral testicular pain have been reported as the described. The presentation has been with severe sole presentation of aneurysmal rupture."' The gluteal pain, restricted straight leg raising and postulated mechanism is haematoma causing pres- normal neurological examination.26 Clearly in the on September 28, 2021 by guest. Protected sure on visceral afferent pain fibres from the testes. situation with a normal lumbar spine X-ray and Massive haematuria has been described as a aortic calcification, one must be wary of ruptured abdominal aortic aneurysm. Other reported presentations include lateral Table I Common misdiagnoses in patients with popliteal nerve palsy with foot drop (attributed to ruptured abdominal aortic aneurysms occlusion of the artery to the sciatic nerve)27 and various root compression syndromes.28 Acute Ureteric colic paraplegia has also been reported as a presentation Prolapsed lumbar intervertebral disc of aneurysmal rupture,27'29 although this is more Sciatica likely to occur as a result ofaortic thrombosis or as Acute myocardial infarction a postoperative complication. Acute sympathetic Perforated peptic ulcer paralysis causing a unilateral warm dry foot can Acute pancreatitis Acute cholecystitis occur as a complication of aneurysmal rupture. Mesenteric vascular occlusion Haematoma causing damage to the sympathetic Acute diverticulitis ganglia has been implicated as the cause.30 The message is that acute painful neuropathies in Postgrad Med J: first published as 10.1136/pgmj.69.807.6 on 1 January 1993. Downloaded from 8 A. BANERJEE the lower limbs and acute nerve root compression inguinal canal.41- This may lead to inguinal syndromes in the middle aged or elderly can be herniorrhaphy as an emergency procedure, when a caused by aortic aneurysmal rupture, which must haemorrhagic hernial sac and/or retroperitoneal be considered