Case 55

70 yoF with PMH of CHF, HTN, HLD, DM2 presents to the ED with abdominal bloating and discomfort for 3 weeks. Denies N/V/D, fever, chills, urinary symptoms, bloody stool, CP, SOB. Last seen by PMD 5 years ago.

T 98.8 (R), BP 180/100, HR 97, RR 16, O2 99% RA

EXAM: Head atraumatic, PERRLA, ears clear BL, throat midline. Heart RRR no MRG. Lungs CTAB. Abd with mild periumbilical discomfort. Extremities warm, well perfused.

Images obtained by ultrasound are seen below. 

 

QUESTIONS
1.     What do you see?
2.     What are the normal dimensions of the aorta?
3.     What are the different views and landmarks needed to identify the aorta by ultrasound?
4.     What are the next steps in the management of this patient?
5.     Where are 95% of abdominal aortic aneurysms located?

ANSWERS

  1. Saccular abdominal aortic aneurysm
  2. The aorta should measure less than 3.0 cm in diameter, and iliac arteries should measure less than 1.5 cm in diameter, measured from outer wall to outer wall.
  3. Proximal aorta: “sea gull” sign which is created by the celiac trunk/axis splitting into the common hepatic artery and splenic artery. The left gastric artery is also part of the celiac axis, but is not visualized during the transabdominal bedside ultrasound scan.
    Middle aorta: “mantle clock” sign created by the superior mesenteric artery and the hyperechoic fat surrounding the vessel.  The splenic vein runs superior to the SMA and the left renal vein runs inferior to the SMA and superior to the aorta.   
    Distal aorta: located just proximal to the iliac bifurcation.
  4. Consult vascular surgery. Medical optimization of blood pressure.
  5. 95% of abdominal aortic aneurysms are located in the infrarenal portion of the aorta.