Correspondence

Computed Tomography for Ruptured Abdominal Aortic Aneurysm?

N Engl J Med 1996; 334:1272-1273May 9, 1996

Article

To the Editor:

The last place an 85-year-old patient with hypotension, severe abdominal pain, and a pulsatile abdominal mass should be is in the computed tomographic (CT) scanner (Images in Clinical Medicine, Jan. 4 issue).1 Instead, this patient should have been taken immediately to the operating room, bypassing the radiology department altogether. This is a classic example of a situation in which physicians must rely on the signs and symptoms found at the bedside and act on their intuition, rather than falling back on unnecessary confirmatory tests.

Steven J. Eskind, M.D.
Surgical Specialists of Nashville, Nashville, TN 37205

1 References

1. 1

   Gervais DA, Whitman GJ. Ruptured abdominal aortic aneurysm. N Engl J Med 1996;334:27-27
   Full Text | Web of Science | Medline

To the Editor:

What in the world could have motivated Drs. Gervais and Whitman to obtain an emergency abdominal CT scan in a patient with a clinically obvious ruptured abdominal aortic aneurysm? This image provided an opportunity to teach a valuable lesson, but unfortunately the wrong lesson has been taught. The Journal should have used the submission of the image to condemn the practice and recommend clinical diagnosis and immediate transfer of the patient to an operating room where personnel have been alerted to the emergency. One is left to wonder what responses this case would have prompted if it had appeared as a Clinical Problem-Solving article.

George Andros, M.D.
2701 W. Alameda Ave., Burbank, CA 91505

Author/Editor Response

The authors reply:

To the Editor: We agree with Dr. Eskind and Dr. Andros that hemodynamically unstable patients with clinically obvious ruptured abdominal aortic aneurysms should be taken directly to the operating room, without diagnostic studies. The patient in this case was not hemodynamically unstable at the time of the CT scan, but had experienced transient hypotension, accompanied in part by bradycardia, which suggested a possible vagal cause. Because he had a known abdominal aortic aneurysm and a history of peptic ulcer disease, his presentation with epigastric pain, nausea, and vomiting led his physicians to consider a gastrointestinal cause in the differential diagnosis. An emergency CT scan was requested and given top priority by both the surgeons and the radiologist in the CT suite, as is consistent with recent suggestions for the close monitoring of patients with symptomatic abdominal aortic aneurysms in the CT suite.1

Among hemodynamically stable patients with symptomatic abdominal aortic aneurysm, Kvilekval et al. have found no difference in mortality between those who undergo CT and those who do not.2 CT is useful, however, in evaluating the extent of the aneurysm, anatomical variants (especially venous and renal), frank as compared with “contained” rupture, and potential inflammatory components.3 Identifying symptomatic nonruptured abdominal aortic aneurysm is important, because the perioperative morbidity from cardiovascular events is lower if repair is deferred until the cardiac issues are addressed.2 CT may also identify clinical conditions that mimic symptomatic abdominal aortic aneurysm, especially in a patient such as ours, in whom there is an alternative diagnostic consideration.4

All hemodynamically unstable patients with clinically obvious ruptured abdominal aortic aneurysms should be taken directly to the operating room. Hemodynamically stable patients with this condition or in whom the diagnosis may be uncertain may benefit from CT, which should be done expeditiously, in consultation with the surgical service. Because the condition of such patients can become unstable at any time, radiologists and surgeons must be prepared to respond rapidly.

Debra A. Gervais, M.D.
Gary J. Whitman, M.D.
Massachusetts General Hospital, Boston, MA 02114

4 References

1. 1

   Cohan RH, Siegel CL. CT of “stable“ patients with suspected abdominal aortic aneurysm with leak or contained rupture. AJR Am J Roentgenol 1995;164:1302-1303
   Web of Science

2. 2

   Kvilekval KH, Best IM, Mason RA, Newton GB, Giron F. The value of computed tomography in the management of symptomatic abdominal aortic aneurysms. J Vasc Surg 1990;12:28-33
   CrossRef | Web of Science | Medline

3. 3

   Siegel CL, Cohan RH. CT of abdominal aortic aneurysms. AJR Am J Roentgenol 1994;163:17-29
   Web of Science | Medline

4. 4

   Kadir S, Athanasoulis CA, Brewster DC, Moncure AC. Tender pulsatile abdominal mass: abdominal aortic aneurysm or not? Arch Surg 1980;115:631-633
   Web of Science | Medline