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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 148-151

A case of Stanford type B acute aortic dissection presenting as acute abdomen


1 Department of Internal Medicine, College of Medicine, Kaduna State University, Tafawa Balewa Way, Kaduna, Nigeria
2 Interventional Cardiology & Vascular Interventions, Indraprastha Apollo Hospital, New Delhi, India

Date of Submission09-May-2018
Date of Decision08-Jun-2019
Date of Acceptance12-Nov-2019
Date of Web Publication04-Feb-2020

Correspondence Address:
Dr. Peter Dodo Yakubu
Department of Internal Medicine, College of Medicine, Kaduna State University, Tafawa Balewa Way, Kaduna
Nigeria
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DOI: 10.4103/ssajm.ssajm_15_18

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  Abstract 


Acute aortic dissection is a medical emergency with high mortality. It presents mostly with typical features of sudden onset chest pain that is tearing in nature and radiates to the back, neck, or the abdomen. However, it may present with atypical features like abdominal pain, nonspecific abdominal or chest discomfort, altered bowel habit, vomiting, and features of acute renal dysfunction leading to diagnostic dilenma. These atypical features are mostly reported in western population. We report a case of 48-year old man with Stanford type B acute aortic dissection that was initially diagnosed as acute abdomen.

Keywords: Acute abdomen, presenting, Standford, type B aortic dissection


How to cite this article:
Yakubu PD, Khanna NN, Edafe EA, Rao S. A case of Stanford type B acute aortic dissection presenting as acute abdomen. Sub-Saharan Afr J Med 2019;6:148-51

How to cite this URL:
Yakubu PD, Khanna NN, Edafe EA, Rao S. A case of Stanford type B acute aortic dissection presenting as acute abdomen. Sub-Saharan Afr J Med [serial online] 2019 [cited 2020 Oct 31];6:148-51. Available from: https://www.ssajm.org/text.asp?2019/6/3/148/277777




  Introduction Top


About 60–70% of patients with acute type B aortic are present typically with severe sudden onset tearing or sharp chest pain that radiates to the back, the neck, or the abdomen. [1] It is more common in hypertensive elderly males when compared to their female counterparts.[1] Acute type B aortic dissection occasionally presents non-specific features of abdominal pain, nonspecific abdominal or chest discomfort, altered bowel habit, vomiting, acute renal dysfunction, neurological deficits, among others without the classical tearing or sharp pains.[2],[3] These are called the atypical features of acute descending aortic dissections.[3] Most of these atypical features are mostly reported from the Western population,[2],[3],[4] hence, the need for this case report to create the awareness that atypical features of aortic dissection are also found in other regions of the world.

We report a case of Stanford type B aortic dissection presenting with severe abdominal abdomen as the chief complaint.


  Case presentation Top


A 48-year old Indian who was a businessman presented to the Emergency Unit of Indraprastha Apollo Hospitals, New Delhi, India, with complains of sudden onset of sharp abdominal pain of 6 hours duration. The pain was generalized but more in the umbilical region and non-radiating. He had no history of vomiting, no change in bowel habit, and no abdominal swelling. There was also no fever, nor headache. The patient is a known hypertensive for five years but not regular on his drugs. His parents had hypertension but no family history of similar illness. He had no history of alcohol used and does not smoke cigarette. Examination showed a conscious middle-aged man, in painful distress. His pulse rate was 116 beats per minutes, blood pressure: 260/110 mmHg. Examination of his abdomen showed severe generalized tenderness and rebound tenderness, making it difficult to palpate the abdominal organs, no bruit on auscultation, no other remarkable examination findings.

An initial working diagnosis of hypertensive urgency and acute abdomen was made. The patient was admitted to the Intensive Care Unit, and reviewed by gastroenterologist, gastrointestinal surgical and Cardiology teams. The abdominal X-ray and ultrasound showed no evidence of bowel obstruction. The liver, the pancreas, and the kidneys were normal.

On the second day of admission, contrast computerized tomographic scan of the abdomen and the chest revealed dissection of the descending aorta [Figure 1]. This necessitated consultation of our team (the interventional cardiology team). We found the patient to be in painful distress, his pulse rate was 116 beats per minute. He had mildly reduced pulse volumes in lower limbs compared to the upper limb peripheral arteries and his blood pressure measurements in the limbs were markedly elevated as follows: left upper limb 260/110 mmHg, right upper limb 268/110 mmHg, right lower limb 230/100 mmHg, left lower limb 260/100 mmHg. He had normal first heart sound, loud aortic component of the second heart sound and fourth heart sound.
Figure 1 Aortic dissection (arrows).

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We made the diagnosis of acute aortic dissection with atypical presentation and acute kidney injury. The patient was then transferred to Coronary Care Unit.

Other laboratory results showed azotemia (Urea: 33.3 mmol/L) and elevated creatinine of 265.2 Umol/L. Serum electrolytes were normal and oxygen saturation was 90%. His random blood glucose was normal (6.7 mmol/L), complete blood count was: Hb: 14.4 g/dl, packed cells volume: 41%, white blood cells count: 2.13 × 103/mm3, RBC: 4.85 × 103/mm3, platelets counts: 190 × 103/mm3, neutrophils: 84%, lymphocytes: 84%, monocytes: 6%.

Echocardiography showed concentric left ventricular hypertrophy, good systolic function with grade 1 diastolic dysfunction. Doppler study of the aorta showed atherosclerotic plaques in abdominal aorta with total occlusion of the right common iliac artery. There was moderate narrowing of the ostium of the left common iliac artery leading to mildly reduced flow in the left renal artery. Highly damped flows in the right femoral artery. No evidence of dissection flap although acoustic window is extremely poor.

Written informed consent for Endovascular Aneurysm Repair (EVAR) was obtained from patient after counselling and the procedure was performed as stated below.


  Procedure Top


Access was secured through the right femoral artery cut-down with the patient under general anesthesia. Puncture needle and 7F sheath were inserted into the right femoral artery. Procedure dye was Omnipaque. A pigtail catheter (4F) was advanced via the femoral artery through the true lumen to the arch of the aorta. Series of the digital subtraction angiography (DSA) were obtained to define the true lumen. Another pigtail catheter was advanced into the aortic arch for the measurement of pressures and DSA to define the exact origin of true lumen and the false lumen. The false lumen was found to be just below the subclavian artery. Terumo wire (0.035) was removed and the Lunderquist wire of 260 cm was passed to the arch of the aorta through a 3.5F JR catheter. At the same time, a balloon was positioned just above the origin of the subclavan artery and inflated to 10 atm. Then, a stent graft (Zenith Cook medical 32 mm x 28 mm x 102 mm) was passed from the right femoral access (over the Lunderquist wire) to just the origin of left subclavan artery and was deployed through the true lumen. The post-deployment DSA was taken and the stent graft found to be in good position. The mesenteric artery and right renal artery were seen arising from the true lumen while the left renal artery from the false lumen [Figure 2]. Procedure was successful [Figure 3] and femoral cut-down was closed.
Figure 2 (a) Left artery arising from the false lumen and (b) the right from the true lumen.

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Figure 3 Deployed stent graft.

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Post-procedure, patient was hemodynamically stable and was discharged four days after the procedure.


  Discussion Top


Aortic dissection is defined as separation of the layers within the aortic wall. Tears in the intimal layer result in the propagation of dissection (proximally or distally) secondary to blood entering the intima-media space.[5] Acute abdomen is sudden onset of severe abdominal pain that requires immediate surgical evaluation or intervention.[6] Mortality due to aortic dissection is still high despite the advancement in its diagnostic and therapeutic modalities.[7]

There are various classifications of aortic dissection. The common ones are the Standford and De-Bakey Classifications. In Standford classification, aortic dissection is classified into type A (involving the ascending aorta) and type B (not involving the ascending aorta).[7] De-Bakey classification are type I (involving the ascending aorta, arch, and the descending aorta), type II (restricted to the ascending aorta), and type III (involving the descending aorta).[8] The Svensson system of classification incorporated intramural hematoma and penetrating aortic ulcer in addition to dissection to come out with five classes as follows: Class 1: Classic dissection with intimal flap separating true and false lumens; Class 2: Intramural hematoma; Class 3: Limited intimal tear with eccentric bulge; Class 4: Penetrating atherosclerotic ulcer; Class 5: Iatrogenic dissection.[9]

The clinical presentation of descending aortic dissection is sudden onset of tearing back pain located between the scapulars bones and often radiates to the abdomen.[10] Pain is classically described as maximum from onset and often associated with dyspnoea, diaphoresis, and weakness. One study reported atypical presentation of aortic dissection in 17% of patients.[10]

Descending aortic dissection less frequently presents primarily with abdominal pain.[11] McCloy and his colleagues studied 50 patients with aortic dissection. They found that patients had abdominal pain as a primary symptom in less than 13%.[11] Slater and De Sanctis found abdominal pain as the main symptom in 6.38% of patients with De-Bakey types I and II and in 2.90% of type III dissection.[12] Ismil and Hussien described an isolated abdominal pain in the epigastric region as a primary symptom of aortic dissection.[13]

The possible mechanisms for primary abdominal pain in patients with type III aortic dissection include: a ruptured or symptomatic abdominal aortic aneurysm and malperfusion of the visceral branches of the abdominal aorta.[14] The chief complaint of our patient was severe abdominal pain presenting as the primary symptom of aortic dissection. He had no neurological complications such as back pain and parentheses. Left renal artery involvement led to the impairment in the renal function of this patient. The patient was first managed by the gastroenterologist/gastrointestinal surgeon because of the sudden onset of severe abdominal pains as the main presenting complain resulting to delay in making the appropriate diagnosis. So, a high index of suspicion is required for early diagnosis and management of such patients.

Open surgery would have been the better treatment option for this patient because of his young age, having normal cardiac function, and also considering the long-term benefit of open surgery over the endovascular repair.[15],[16] It is however associated with high mortality and morbidity especially in patients with significant renal disease and severe aneurysm symptoms.[17] The transcutaneous endovascular repair (EVAR) was chosen because of its advantage of lower overall mortality and better immediate morbidity in this patient with suitable anatomy who also had severe life threatening symptoms in addition to the significantly deranged renal function.[15],[16],[18]


  Conclusion Top


Severe abdominal pain as main presentation is a rare manifestation of type III aortic dissection. Awareness of possible aortic dissection with high index of suspicion is the key point leading to an early diagnosis in patients with atypical presentation.

Financial support and sponsorship

Nil.

Conflicts of interest

No conflicts of interest to declare.



 
  References Top

1.
Hagan PG, Niebnabar CA, Isselbacher EM, Bruckmn D, Karavite DJ, Russman PL et al. The international registry of acute aortic dissection (IRAD): new insight into an old disease. JAMA 2000;283:897-903.  Back to cited text no. 1
    
2.
Park SW, Hutchison S, Mehta RH, Cooper JV, Fang J, Evangelista A et al. Association of painless acute aortic dissection with increased mortality. Mayo Clin Proc 2004;79:1252-7.  Back to cited text no. 2
    
3.
Nienaber CA, Eagle KA. Aortic dissection: new frontier in diagnosis and management. Circ 2003;108:628-35.  Back to cited text no. 3
    
4.
Spitell PC, Spitell JA Jr, Joyce JW, Tajik AJ, Edwards WD, Schaff HV et al. Clinical feature and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). Mayo Clin Proc1993;68:642-51  Back to cited text no. 4
    
5.
Mancini MC. Aortic dissection. Available at https://emedicine.medscpe.com/article/2062452-overview. Accessed on the 22/09/2019.  Back to cited text no. 5
    
6.
Nwashilli NJ, Okobia NM, Osime OC, Agbugui OJ. The pattern and outcome of surgical acute abdomen at a Nigerian tertiary hospital. Nig J Surg Sc 2017;27:51-6  Back to cited text no. 6
    
7.
Daily PO, Trueblood HW, Stinson EB, Wuerflein RD, Shumway NE. Management of acute aortic dissections. Ann Thorac Surg 1970;10:237-47.  Back to cited text no. 7
    
8.
DeBakey ME, Beall AC Jr, Cooley DA et al. Dissecting aneurysms of the aorta. Surg Clin N Am 1966;46:1045-55.  Back to cited text no. 8
    
9.
Svensson LG, Labib SB, Eisenhauer AC, Butterly JR. Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques. Cir 1999;99:1331-6.  Back to cited text no. 9
    
10.
Imamura H, Sekiguchi Y, Iwashita T, Dohgomory H, Mochizuki K, Aizawa K et al. Painless acute aortic dissection: diagnostic, prognostic and clinical implication. Circ 2011;75:59-66.  Back to cited text no. 10
    
11.
McCloy RM, Spittell JA Jr, Mcgoon DC. The prognosis in aortic dissection (dissecting aortic hematoma or aneurysm). Circ 1965;31:665-9.  Back to cited text no. 11
    
12.
Slater EE, DeSanctis RW. The clinical recognition of dissecting aortic aneurysm. Am J Med 1976;60:625-33.  Back to cited text no. 12
    
13.
Ismil ML, Hussien M. Unusual presentation of dissecting aortic aneurysm. Int J Clin Pract 1999;53:389-90.  Back to cited text no. 13
    
14.
Upchurch GR Jr, Nienaber C, Fattori R, Evangelista A, Oh J, Isselbacher E et al. Acute aortic dissection presenting with primarily abdominal pain: a rare manifestation of a deadly disease. Ann Vasc Surg 2005;19:367-73.  Back to cited text no. 14
    
15.
Patel R, Sweeting MJ, Powell JT, Greenhalgh RM. The UK Endovascular Aneurysm Repair (EVAR) randomized controlled trials: long-term follow-up and cost effectiveness analysis. Health Technol Assess 2018;5:1-132.  Back to cited text no. 15
    
16.
Patel R, Sweeting MJ, Powell JT, Greenhalgh RM. Endovascular versus open repair of abdominal aortic aneurysm in !5 years follow-up of the UK endovascular aneurysm trial 1(EVAR 1): a randomized controlled trial. Lancet 2016;388:2366-74.  Back to cited text no. 16
    
17.
Crawford ES, Svenson LG, Costelli JS, Safi HJ, Hess KR. Surgical treatment of aneurysm and/or dissection of ascending aorta, transverse aortic arch and ascending aorta and transverse thoracic arch. J Thoracic and Cardiovasc Surg 1989;98:658-74.  Back to cited text no. 17
    
18.
Iannacone E, Grardi L. Thoracic endovascular aortic repair versus open versus medical management of type B dissection. J Vis Surg 2018;4:8  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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