Symptomatic abdominal aortic aneurysms may present as syncope, back or belly pain, shock, or sudden death. Sudden death most commonly occurs from intraperitoneal rupture of the aneurysm. These ruptures lead to massive, rapid blood loss and it will not be possible to resuscitate the patient. History that is often cited as classic for acute rupture of the abdominal aneurysm is syncope with no warning symptoms followed by severe abdominal or back pain. Syncope is caused by rapid blood loss and a lack of cerebral perfusion. Patients often regain consciousness after their own compensatory mechanisms have been invoked, but they will most often slip again into shock without prompt medical intervention.
Patients will most often present with variations on the classic history. 2 Pain may occur before syncope, and the pain may not be severe in some cases. The pain also may be unilateral and may be located in a flank, costovertebral angle of the groin, or in a single quadrant of the abdomen. Hip pain, tenesmus, and urinary bladder symptoms have been described. Constitutional symptoms such as nausea and vomiting are commonly present.
Physical examination of a patient with acute rupture of an aortic aneurysm may detect the aneurysm. Tenderness to palpation of an aneurysm is commonly interpreted as a sign of rupture. However, a lack of tenderness cannot imply an intact aorta. Patients with an obese abdomen are difficult to exam for the presence of an aortic aneurysm. Very thin patients may have an aorta that is easily palpable, and the diameter of the aorta should be measurable.
Evidence of retroperitoneal hematoma may be seen as periumbilical ecchymosis (Cullen's sign) or flank ecchymosis (Grey-Turner's sign). Retroperitoneal blood may also dissect into the perineum or groin. Scrotal hematomas or inguinal masses may be seen on exam. Retroperitoneal blood may also irritate the psoas muscle and produce an iliopsoas sign. Blood may compress the femoral nerve and present as a neuropathy. The presence or rupture of an AAA does not typically alter femoral arterial pulsations.6
Aortoenteric fistulas must be considered in all patients with unexplained gastrointestinal bleeding. A history of aortic graft placement should increase the clinical suspicion of fistula.7 The duodenum is most frequently involved; and therefore bleeding may manifest as hematemesis, melenemesis, melena, or (if there is rapid transport) hematochezia. These fistulas commonly present as massive, life-threatening bleeding. However, mild "sentinel" bleeding may precede a full-blown rupture. Aortic aneurysms may also erode into the venous vasculature and form aortovenous fistulas, which may present as high-output cardiac failure, decreased arterial blood flow distal to the fistula, and increased central venous volume.
Abdominal aortic aneurysms may uncommonly present as chronic contained ruptures.8 A retroperitoneal rupture may cause enough fibrosis to limit blood loss. The inflammatory response commonly causes pain, which may continue for a significant length of time. Despite the seriousness of this pathology, the patient may appear remarkably well.
An asymptomatic aneurysm may be found on physical examination or radiologic evaluation. Any aneurysm that is found should be referred for follow-up. Aneurysms greater than 5 cm in diameter are at an increased risk of rupture. Aneurysms of less than 5 cm are unlikely to rupture, however, patients with such asymptomatic aneurysms must be closely followed by their primary care physicians or surgeons. The management of patients with small, asymptomatic aneurysms (including the timing of surgery) is a controversial topic.29 Symptomatic aneurysms of any size should be considered emergent.
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