Clinical case 038: a AAA eh?
Todays case – 69 yo woman presents to ED with 3 hour history of sharp, severe left abdominal pain. Pain is colicky, radiating down into groin. Urinalysis shows 2+ blood.
So if you read the “frolic with colic” post and the wise comments from the readers you will be asking for an ultrasound – not to diagnose a stone, but to rule out a AAA rupture. So off to the dark room, maybe you are a keen US type and you have a look yourself. So you pick up the probe and identify the aorta, then follow it down and is bulges out just below the renal vessels to a max. diameter of 3.9 cm….
This case got me thinking. I know there are a lot of ED / Gp docs out there who are keen on bedside sonography. And looking at the aorta is not the toughest utility for those with a small amount of training. But, the big problem isn’t finding the pathology – rather knwing what it means and what to do about it. So here is a quick review on the topic. Most of the info here is pulled from a nice review article, written by my former boss Mr Paul Norman and Dr Powell in Circulation 2007. It is worth a read if you have time. The super simple summary is that:
- most of what we know about AAAs comes from data which is heavily skewed towards men.
- Female AAAs grow faster than those in men
- Women have a higher rupture rate (~4x) for a similar diameter AAA c/w men
- Women are technically more tricky to do repairs on, esp. endoluminal.
- Women tend to be managed “non-surgically” in rupture at higher rates than men.
- Basically, women seem to get the raw end of the deal in every department when it comes to AAA
- The rates of AAA are climbing faster in women (?late lag effect of smoking)
Q:
Of course, the job of the GP is to counsel the patient and do so in the context of other comorbidities and the patient’s own risk beliefs. After all, this is not trivial surgery. There are serious comlications and an appreciable surgical mortality.
This paper in Annals of Surgery 2010 looked at the mortality rates for elective repair @ 28 days, 1 year and 5 years. Being older, female and having comorbidities had a large effect on survival – up to 50% mortality in some groups!
So next time you scan a belly and go looking for an aorta, just recall – you might find something, and if what you are doing amounts to screening you just might be opening a whole can of worms for this patient. Consider their age, sex and comorbidities. You just might save a life, you also might start the ball rolling on a course of events that the patient never wanted. This is the downside of widespread bedside US for me – finding stuff that you wished you hadn’t!.