Aneurysm cases
30-06-2022 -by Peek Nieuwenhuisen – GP Research Committee and Elke Koestering – VIM Committee
In the first quarter of 2022, three VIM reports were reported to us regarding (missing) an AAA. In all three of these reports, the patient died. An example of such a difficult case is a man with acute pain in his back and radiation to his abdomen, who recognizes the symptoms of previous back problems. Proper check-ups and pressure pain of the back lead to a wrong diagnosis. The symptoms of an abdominal aneurysm can be non-specific, which can make it difficult to recognize and interpret it.
The classic symptoms of an AAAA are acute severe tearing abdominal or back pain with vegetative symptoms, ABCDE instability in which a pulsating mass is palpable on palpation. In this situation, the aneurysm has ruptured and there is a very acute situation with high mortality. Before this stage, the aneurysm can cause symptoms that can be very non-specific and can occur intermittently. The vascular wall is unstable but not (yet) ruptured. This can cause complaints that can be triggered by, for example, physical exertion. The following symptoms and characteristics may indicate an unstable aneurysm:
- Acutely occurring abdominal and/or back pain, whether or not radiating to one or both legs
- Vegetative symptoms at the onset of pain
- This cannot be logically explained by another cause, such as extensive history, back pain, known abdominal problems, etc.
- Usually over 65 years of age
- Intermittent course
- In case of palpation of the abdomen: abdominal pain or pain radiating to the back that can be induced by pressure at the site of the aneurysm, with or without palpable (pulsating) mass. Incidentally, normal ABCDE values and a non-abnormal abdominal examination do not rule out an unstable AAA.
Risk factors
- Men. Incidentally, women can of course also get an (A)AAA, but less often have a symptomatic unstable preliminary phase
- Age: almost all patients with an (A)AAA are 65 years of age or older
- Previous cardiovascular events, especially previous myocardial infarctions or manifestations of peripheral artery disease
- Cardiovascular risk factors: especially smoking and hypertension
- Taxed family history
- Already familiar with aneurysm: the occurrence of a collapse in a known aneurysm indicates an unstable AAA until proven otherwise.
Policy
- The combination of acute abdominal and/or back pain and vegetative symptoms gives the triage result U1-ambu. Especially with a classic AAAA, this is the only correct policy.
- In case of an unstable AAA, you may find a non-sick patient with no abnormalities on physical examination. Patients with the above symptoms and multiple risk factors and for whom no conclusive alternative explanation is found are suspected of an unstable AAA and should be referred to the ED for further analysis.
The above sounds simple on paper, but in practice it is usually not. It is important to:
- To be alert to a non-specific course with good controls. Ask risk factors carefully. To have AAA in the differential diagnosis and to appoint it if necessary.