Case of a pulsatile abdominal mass reported in NEJM

Dr Maxime Elens, and Dr Robert Verhelst, at Cliniques Universitaires Saint-Luc, Brussels, Belgium have reported a case of Pulsatile Abdominal Mass. The case has appeared in the New England Journal of Medicine.

The assessment of a patient with a pulsatile abdominal mass is the possibility of a leaking or ruptured Abdominal Aortic Aneurysm (AAA). Other serious abdominal pathologies may demonstrate the same clinical signs but require entirely different treatments. Even amongst patients with proven abdominal aortic aneurysms CT imaging findings may influence the timing and nature of the surgery and provide useful prognostic information. Generally, an arterial aneurysm is defined as a localized arterial dilatation ≥50 % greater than the normal diameter.

Although the most important and potentially life-threatening diagnosis of this clinical finding is an abdominal aortic aneurysm (AAA), this sign may be caused by other pathologic as well as non-pathologic conditions. A list of possible differential diagnoses includes: a thin abdominal wall, an intra-abdominal mass, a congested liver associated with severe tricuspid regurgitation, aneurysm/pseudoaneurysm of splanchnic vessels, etc. These differential diagnoses should be kept in mind and considered particularly in nonclassic clinical scenarios.

A 66-year-old man presented to the emergency department with a 2-month history of abdominal bloating and worsening constipation. His medical history was notable for untreated hypertension and hyperlipidemia. He had been an active smoker for more than 20 years, and his father had died suddenly at 62 years of age from an unknown cause.

The patient’s blood pressure was 162/83 mm Hg, and the physical examination revealed a painless pulsatile abdominal mass (see video). The femoral pulses were palpable on both sides. Computed tomographic angiography revealed a large fusiform infrarenal aortic aneurysm measuring 11 cm by 10.5 cm by 14 cm.

The patient underwent surgery, during which the aneurysm was exposed and replaced with an aortobiiliac graft. He also began medical treatment for hypertension and hyperlipidemia. At a 6-month follow-up visit, the patient had no pulsatile abdominal mass, had good perfusion to his legs, and felt well.