Presentation
Unbearable abdominal pain.
Patient Data
Bilateral partly thrombosed huge internal iliac artery (IIA) aneurysms, the left descending deep into the pelvis. The right aneurysm is ruptured and shows active bleeding that grows (continues) in the portal phase. There is a massive amount of retroperitoneal blood.
Said aneurysms cause chronic massive bilateral hydroureteronephrosis; the left renal parenchyma is considerably thinned.
Partly thrombosed large LAD aneurysm.
Several hypodense, non-enhancing areas in the spleen (non-contrast scan not shown), likely representing infarctions.
Radiographic picture of median arcuate ligament syndrome.
Inferior phrenic arteries originate from the celiac trunk, right hepatic artery replaced to the SMA - anatomical variants.
Case Discussion
A patient previously unknown to the ER had gone to relieve himself at home, fainted for a few seconds and came to but was very pale. Presented to the ER with weakness and an excruciating abdominal pain. The first thought was a complication of diverticulitis, since he was on combined antibiotic treatment for recently diagnosed diverticulitis. His blood pressure plummeted to 70/40 mmHg in the ER.
CT abdomen showed huge bilateral IIA aneurysms causing massive hydroureteronephrosis and rupture of the right IIA with massive retroperitoneal hemorrhage.
Despite prompt treatment at the vascular surgery unit, plus receiving whole blood, FFP, vasopressin and norepinephrine, he unfortunately crashed hemodynamically, developed ventricular tachycardia, then asystole almost immediately and passed away.
It is possible that increasing intra-abdominal pressure during the Valsalva maneuver is what caused the aneurysm to rupture. Given the LAD aneurysm, it is also possible that the patient had a connective tissue disease.
Unable to process the form. Check for errors and try again.