Updated: 5/31/2019

Abdominal Aortic Aneurysm

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Snapshot
  • A 67-year-old man presents to his primary care physician due to vague epigastric discomfort. He denies it being associated with meals and reports that this pain occurred insidiously.  Medical history is significant for hypertension. He has been smoking 1-pack of cigarettes per day for the past 30 years. On physical exam, he has a pulsatile abdominal mass that is tender to palpation. An abdominal ultrasound is performed, which demonstrates a 6 cm abdominal aortic aneurysm. He is scheduled for an elective abdominal repair surgery for the following day.
Introduction
  • Clinical definition
    • a segmental and full thickness dilation of the abdominal aorta 
  • Epidemiology
    • risk factors
      • age
      • male gender
      • cigarette smoking (greatest risk factor) 
      • family history
      • Caucasian race
      • atherosclerosis
  • Pathogenesis
    • pathoanatomy
      • the abdominal aorta is a retroperitoneal structure that
        • begins in the hiatus of the diaphragm
        • bifurcates into the right and left iliac common arteries
          • these arteries can also become aneurysmal
      • an aneurysm typically develops below the renal arteries and above the common iliac arteries
    • pathophysiology
      • elastin fibers become disrupted and collagen becomes degraded, resulting in a loss of elasticity in the aortic wall
  • Prognosis
    • risk of rupture increases with size
Presentation
  • Symptoms/physical exam 
    • asymptomatic (the majority of cases)
      • an enlarged abdominal mass and an abdominal bruit may be found
    • in symptomatic but not ruptured cases
      • abdominal, back, or flank pain
    • in symptomatic and ruptured cases
      • severe pain, hypotension, and a pulsatile mass
Imaging
  • Abdominal CT (contrast-enhanced) 
    • indication
      • in symptomatic patients who are hemodynamically stable 
  • Abdominal ultrasound
    • indication 
      • USPSTF recommends that screen be performed 1 time in men who
        • are 65-75 years of age
        • smoked at any time
      • serial imaging in patients with an abdominal aortic aneurysm (AAA) < 5 cm
Treatment
  • Conservative
    • smoking cessation
      • indication
        • for all patients
  • Operative
    • AAA repair  
      • indication
        • ruptured AAA (surgical emergency)  
        • symptomatic and unruptured cases
          • abdominal aortic aneurysm ≥ 5.5 cm
Complications
  • Rupture
 

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Questions (7)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.CV.19) A 79-year-old man presents to the emergency department with abdominal pain. The patient describes the pain as severe, tearing, and radiating to the back. His history is significant for hypertension, hyperlipidemia, intermittent claudication, and a 60 pack-year history of smoking. He also has a previously diagnosed stable abdominal aortic aneurysm followed by ultrasound screening. On exam, the patient's temperature is 98°F (36.7°C), pulse is 113/min, blood pressure is 84/46 mmHg, respirations are 24/min, and oxygen saturation is 99% on room air. The patient is pale and diaphoretic, and becomes confused as you examine him. Which of the following is most appropriate in the evaluation and treatment of this patient? Review Topic

QID: 103042
1

Abdominal ultrasound

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2

Abdominal CT with contrast

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3

Abdominal CT without contrast

0%

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4

Abdominal MRI

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5

Surgery

100%

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(M3.CV.2) A 68-year-old male with past history of hypertension, hyperlipidemia, and a 30 pack/year smoking history presents to his primary care physician for his annual physical. Because of his age and past smoking history, he is sent for screening abdominal ultrasound. He is found to have a 4 cm infrarenal abdominal aortic aneurysm. Surgical repair of his aneurysm is indicated if which of the following are present?
Review Topic

QID: 103654
1

Abdominal, back, or groin pain

67%

(2/3)

2

Smoking history

33%

(1/3)

3

Diameter >3 cm

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Growth of < 0.5 cm in one year

0%

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5

Marfan's syndrome

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(M3.CV.23) A 73-year-old woman with a history of hypertension, diabetes, and coronary artery disease presents to the emergency department with severe back pain. She states that the pain started approximately 30 minutes ago and she has felt lightheaded and dizzy ever since its onset. Her temperature is 98.1°F (36.7°C), blood pressure is 80/50 mm Hg, pulse is 130/min, respiratory rate is 17/min, and oxygen saturation is 98% on room air. A bedside ultrasound of the abdomen is performed as seen in Figure A. What is the best next step management for this patient's current presentation? Review Topic

QID: 103046
FIGURES:
1

CT scan

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2

Discharge and serial outpatient ultrasounds

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3

Endovascular surgical repair

100%

(2/2)

4

Tranexamic acid

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5

Volume resuscitation and observation

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