Week 11 - Case One Flashcards
what does an AAA refer to
the dilation of the abdominal aorta with a diameter of more than 3cm
often, when is the first time a patient becomes aware of an aneurysm
when it ruptures, causing life-threatening bleeding into the abdominal cavity
what is the mortality rate of a ruptured AAA
80%
what are the risk factors for an AAA
Men are affected significantly more often and at a younger age than women
Increased age
Smoking
Hypertension
Family history
Existing cardiovascular disease
what is the screening programme for an AAA
all men in England are offered a screening ultrasound scan at the age of 65 to detect asymptomatic AAA
are women offered screening
not routinely offered screening as they are at much lower risk.
what do the NICE guidelines say about screening women
the NICE guidelines say a routine ultrasound can be considered in women over 70 with risk factors such as existing cardiovascular disease, COPD, family history, hypertension, hyperlipidaemia or smoking
what aortic diameter counts to refer people to the vascular team
patients with an aortic diameter above 3cm are referred and are referred urgently if more than 5,5cm
what is the presentation of AAA
most patients are asymptomatic. it may be discovered on routine screening or when it ruptures
what are the other ways it can present
non-specific abdominal pain
pulsatile and expansile mass in the abdomen when palpated with both hands
as an incidental finding on an abdominal X-ray, ultrasound or CT scan
what is the usual investigation for establishing a diagnosis of AAA
an ultrasound
why is a CT angiogram sometimes given
gives a more detailed picture of the aneurysm and helps guide elective surgery to repair the aneurysm
what are the four classifications of aneurysm
Normal: less than 3cm
Small aneurysm: 3 – 4.4cm
Medium aneurysm: 4.5 – 5.4cm
Large aneurysm: above 5.5cm
what can the risk of AAA progression be reduced by
treating reversible risk factors;
stop smoking
healthy diet and exercise
optimising the management of hypertension, diabetes and hyperlipidaemia
what screening and surveillance programme is recommended by Public Health England
yearly for patients with aneurysms 3-4.4cm
3 monthly for patients with aneurysms 4.5-5.4cm
the NICE guidelines recommend elective repair for patients with what symptoms
Symptomatic aneurysm
Diameter growing more than 1cm per year
Diameter above 5.5cm
what is involved in elective surgical repair
inserting an artificial graft into the section of the aorta affected by the aneurysm
what are the two methods used to insert this graft
open repair via a laparotomy
endovascular aneurysm repair (EVAR) using a scent inserted via the femoral arteries
what does gov.uk advise that patients MUST do - concerning driving
Inform the DVLA if they have an aneurysm above 6cm
Stop driving if it is above 6.5cm
Stricter rules apply to drivers of heavy vehicles (e.g., bus or lorry drivers)
how does a ruptured AAA present
Severe abdominal pain that may radiate to the back or groin
Haemodynamic instability (hypotension and tachycardia)
Pulsatile and expansile mass in the abdomen
Collapse
Loss of consciousness
what is permissive hypotension
strategy of aiming for a lower than normal blood pressure when performing fluid resuscitation
the theory is that increasing the BP may increase blood loss
what should happen to a haemodynamically unstable patient with a suspected AAA
should be transferred directly to theatre.
surgical repair should not be delayed by getting imaging to confirm the diagnosis.
what can be used to diagnose or exclude ruptured AAA in haemodynamically stable patients
CT angiogram
what is the difference between a true and false aneurysm
a true aneurysm - the wall of the artery forms the wall of the aneurysm
a false aneurysm - other surrounding tissues form the wall of the aneurysm
where are AAA usually found
in the infrarenal part of thr aorta
what are the features of pain in an AAA
epigastric pain radiating to the back. pain may also be present in the groin, illiac fossa or testicles
what is a common feature of a thoracic aortic aneurysm
BP may be different in each arm
what is the mechanism of referred pain
pain of visceral origin is referred to the site on the skin that follows the dermatome rule.
beware of overlapping dermatomes from borderline structures between foregut and midgut. (pancreatic and duodenal in particular)
what are the possible diagnoses for colicky abdominal pain that is now constant
bowel obstruction with/without hernia
irritable bowel syndrome
what are the possible diagnoses for colicky abdominal pain associated with diarrhoea
gastroenteritis
inflammatory bowel disease
Give any possible diagnoses for the description of the pain:
Central abdominal pain that shifted to the right iliac fossa
Appendicitis
Rarely perforated Duodenal Ulcer
Give any possible diagnoses for the description of the pain:
Sudden severe pain radiating to the back, flank and/or groin
Abdominal aortic aneurysm (AAA) until proven otherwise
Renal colic
Give any possible diagnoses for the description of the pain:
Severe generalised pain with shoulder tip pain
Diaphragm irritation by free fluid / blood within the abdomen
what does colicky pain that becomes constant suggest
that there is a partial obstruction of the hollow viscus, that has become complete and needs urgent intervention to prevent perforation/major complication
what does pyrexia, localised tenderness and guarding suggest
an infection or inflammatory process in one organ
what does radiation usually point to
the possible organ but it can also suggest the progression of the disease
what are nausea, vomiting and distension related to
the bowel obstruction but rememeber that inflammatory causes can also cause localised ileus giving a similar but less severe picture
what is McBurney’s point
classical point of maximum tenderness in appendicitis, corresponding to the position of the base of the appendix.
1/3rd of the line between anterior superior iliac spine to umbillicus
what is the definition of a hernia
defined as a protrusion of an organ through its containing wall and into a different cavity
what is the most common abdominal wall hernia
inguinal
what are direct hernias
the leading area of weakness is the posterior wall of the inguinal canal, where viscera herniates anteriorly through Hesselbach’s triangle and not into scrotum
what are indirect hernias
the leading area of weakness is the deep inguinal ring where intra-peritoneal contents herniate into the inguinal canal alongside spermatic cord, and can exit the canal through the superficial ring and into the scrotum
what are the other four types of hernia
Umbilical / paraumbilical
Femoral (Below the inguinal ligament, inferior and lateral to the pubic tubercle)
Incisional (through any previous surgical scar)
Epigastric or midline hernias, where there are natural areas of weakness due to the ‘criss-crossing’ of fibres that form the linea alba
what is a sentinel loop
a short segment of adynamic ileus close to an intra-abdominal inflammatory process.
the sentinel loop may aid in localising the source of inflammation.
