Examine this patient's abdomen.

This patient presented with low back pain; examine the abdomen.



· Remember, three quarters of the patients are asymptomatic.

· Vague abdominal pain.

· History of embolization.

· Family history of rupture of abdominal aneurysm.

· History of smoking.


· Large expansile pulsation along the course of the abdominal aorta.

· Auscultate for bruit over the aneurysm and over the femoral pulses.

· 'Trash' foot - digital infarcts in patient with easily palpable pulses (suggests either a popliteal or abdominal aneurysmal source of emboli) (BMJ 2000; 320:1193-6).

· Examine all peripheral pulses.

Proceed as follows:

· Tell the examiner that you would like to check the following: - Urine for sugar. - Blood pressure. - Serum cholesterol.

· Remember that:

-Popliteal artery aneurysms often coexist and, in fact, their presence should prompt the physician to look for an abdominal aortic aneurysm.

-Ninety per cent of atherosclerotic abdominal aortic aneurysms are present below the origin of the renal arteries and can involve the aortic bifurcation. -The infrarenal aorta is normally 2 cm in diameter; when it exceeds 4 cm an aneurysm is said to exist.

-True arterial aneurysms are defined as a 50% increase in the normal diameter of the vessel. The aneurysmal process may affect any medium or large sized artery.

-The vessels most commonly affected are the aorta and iliac arteries, followed by popliteal, femoral and carotid arteries.


This patient has a large pulsatile mass in the epigastrium (lesion) due to an aneurysm of the abdominal aorta (aetiology).

Read classic reviews on this subject: N Engl J Med 1993; 328:1167; BMJ 2000; 320:1193-6.


Which investigations would you perform to confirm your diagnosis?

· B mode ultrasonography of the abdomen - a simple, cheap and accurate screening test.

· Large aneurysms require angiography.

· Magnetic resonance imaging is useful, particularly as it does not require admin-istration of contrast.

· Remember that plain abdominal radiography shows a calcified aneurysmal aortic wall in only half the cases.


How would you manage an abdominal aneurysm?

· Pooled data suggest that aortic aneurysms of more than 55 mm carry a high risk of rupture and hence should be referred to the

vascular surgeon for surgery if there are no confounding factors that increase the risk of surgery.

· The UK small aneurysm trial studied 1090 patients with an aortic diameter of 40-50 mm and found a 30-day mortality of 5.8%, mean annual risk of rupture for small aneurysms of 1%, and no difference in survival between the treatment groups at two, four or six years (Lancet 1998; 352: 1649-55). Smaller aneurysms must be followed up; they enlarge at a rate of about 0.5 cma year. In selected cases an endovascular prosthesis is preferred.

What factors predispose to rupture of the abdominal aneurysm?

· Diameter of the aneurysm.

· History of smoking.

· Diastolic blood pressure.


· Family history of ruptured aneurysm.

· Rate of expansion.

· Inflammatory aneurysms.

What is the prognosis of aneurysms greater than 55 mm?

The mortality rate for a patient undergoing elective surgery is less than 5%, whereas that for a ruptured aneurysm is nearly 90%.

In 1951, C. Dubost from Paris performed the first successful aortic resection for aneurysm.