Loin pain

Question 1

What would be the most concerning differential in an older male with loin pain radiating to the back? What are some other differentials?

Answer 1

AAA
- renal colic
- pyelonephritis
- GI

Question 2

What finding on abdominal examination would indicate ruptured AAA?

Answer 2

expansile pulsatile mass

Question 3

What are the clinical signs and symptoms suggestive of ruptured AAA?

Answer 3

• sudden onset back or loin pain
• expansile pulsatile abdominal mass
• hypotension and peripheral shutdown
• pallor

Question 4

What are the signs and symptoms of renal colic?

Answer 4

• intermittent sharp flak pain
• pain comes in waves
• may have haematuria
• haemodynamically stable

Question 5

What are the signs and symptoms of pyelonephritis?

Answer 5

• pyrexia
• rigors
• renal angle tenderness
• pain on balloting kidneys

Question 6

What are the signs and symptoms of diverticulitis?

Answer 6

• peritonitis
• lower abdo pain
• sepsis

Question 7

What diameter of the aorta indicates emergency surgery?

Answer 7

> 5.5cm

Question 8

What would you do if USS found 5.9cm AAA?

Answer 8

Pt requires emergency surgery
Inform:
- senior vascular surgeons
- anaesthetics and critical care
- theatre coordinator
- blood bank and haematology

Preop prep:
- reassess patient and optimise for surgery
- if pt clinically stable, follow senior advice and order imaging e.g. thin-slice contrast-enhanced arterial-phase CT angiogaraphy
- chase bloods and crossmatch
- make pt NBM, prepare consent form and preop marking sites

Question 9

What is the management of BP in ruptured AAA?

Answer 9

BP drop may mean progression of rupture
pt may not be fit for imaging e.g. CT angio
aggressive fluid resus may inc BP and worsen rupture. balance with end-organ perfusion
permissive hypotension should be used, guided and closely monitored by senior anaesthetists/intensivists

Question 10

How is ruptured AAA managed?

Answer 10

If pt stable, they should have thin-slice contrast arterial-phase CT angio and decisions made by vascular MDT
Endovascular Aneurysm Repair (EVAR) is preferrable to open surgery in men >70, and women
Open is good for men <70

Question 11

Aneurysms related to which branch of the aorta are most significant in terms of patient morbidity?

Answer 11

The renal artery:

Suprarenal and pararenal abdominal aortic aneurysms result in worse outcomes compared with infrarenal (85% of all AAAs). This is because the management of suprarenal aneurysms has a higher risk of compromising renal blood supply with resulting morbidity.

Question 12

What is the NHS Abdominal Aortic Aneurysm Screening Programme?

Answer 12

The NHS abdominal aortic aneurysm (AAA) screening programme is available to all men aged 65 and over in the UK and aims to reduce AAA mortality in men aged 65 to 74 by screening for AAAs using ultrasound.

<3cm is no aneurysm
3-4.4cm - yearly monitoring
4.5cm-5.4cm - 3-monthly monitoring
>5.5cm needs vascular referral and CTA

Question 13

What are the risk factors for AAA?

Answer 13

• Older age
• Male
• Smoking
• Hypertension
• Atherosclerotic disease
• Connective tissues disorders such as Marfan syndrome, Ehlers-Danlos syndrome.