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Computed Tomography for Suspected
Ruptured Abdominal Aortic Aneurysm?
False-Positive Clinical Diagnoses.
Our Experience at an Insular Hospital.

Alonso, Eva M; Martínez, José A.

Hospital (INSALUD) Can Misses, Ibiza, Spain

SUMMARY
Introduction: Ruptured abdominal aortic aneurysm may be misdiagnosed as other diseases, leading to significant delay in treatment. The correct diagnosis was made by CT. Purpose: to report our experience of false-positive clinical diagnoses confused with ruptured abdominal aortic aneurysm.
Materials and Methods: CT scans, and medical records of 10 patients, 1994-2000, with clinical misdiagnosis of ruptured abdominal aneurysm were reviewed. All patients were evaluated for: (clinical records: age and gender; maximum aortic size, etiology or site of active bleeding, anatomical spread of hematoma and outcome).
Results: Males (7/10), females (3/10), 4/10 (40%) died. Averaged age: 50. No abdominal aneurysm was found. Etiology-Site of rupture: pancreatic pseudoaneurysm, enphysematous pancreatitis, necrohemorrhagic pancreatitis, wünderlich syndrome, aortic dissection: celiac-trunk, (2) left iliac, massive rectus sheath haematoma, and 2 gynecological massive bleeding neoplasms: inmadure and malignant teratoma and sarcoma uterine.
Hematoma extended into retroperitoneum in 40%, around pancreatic gland and perirrenal space, and mainly in pelvis in 60%. We identified active and the source of bleeding in all cases. Our results were confirmed by surgery.
Discussion: CT is the technique of choice for evaluating these patients, they can be scanned rapidly while they are closely monitored. Most patients come hemodynamically stable, and are referred to CT. Other causes of abdominal pain (including aortic dissection, rectus sheath haematoma, retroperitoneal: pancreatic, kidney/ adrenal diseases or gynecological bleeding) are shown in our report by CT. In all these cases, no aneurysm was found. Misdiagnosis is estimated in recent series in 4-20% of patients, leading to significant delay in treatment.
Conclusion:We believe that all patients hemodynamically stable with suspected ruptured abdominal aneurysm, in whom this diagnosis may be uncertain, would benefit from CT. The surgeon and the radiologist must be prepared to respond rapidly, these patients may become unstable at any time.

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INTRODUCTION
   Mortality from ruptured abdominal aortic aneurysm is very high. Overall, between 77-94% of these patients will die. In addition, surgical mortality rates range between 32-70%. But, only a few patients, about (26%), in recent studys, come to the hospital with the classic triad of abdominal pain, hypotension and a pulsatile abdominal mass. Most of them, hemodinamically stable, are referred to CT department to elucidate the correct diagnosis.

   Ruptured abdominal aortic aneurysm may be misdiagnosed as other diseases, leading to significant delays of treatment. Misdiagnosis was much more common in patients in whom a pulsatile mass could not be palpated. The correct diagnosis was almost made entirely on the basis of CT findings.

PURPOSE
   3 to report our experience of false-positive clinical diagnosis, with special attention to other retroperitoneal diseases, confused with ruptured abdominal aortic aneurysm.

MATERIALS AND METHODS
   Patients were imagined on Siemens-Somaton-DR-non helicoidal CT. Contiguous 10-mm-thick images are obtained from the diaphragm through the pelvis. All patients received oral and i.v contrast material to facilitate the distinction of the third and fourth portion of duodenum from a possible small periaortic hematoma.

   CT scans, and medical records of 10 patients, 1994-2000, with clinical misdiagnosis of ruptured abdominal aneurysm were reviewed. All patients were evaluated for: (clinical records: age and gender; maximum aortic size, etiology or site of active bleeding, anatomical spread of hematoma and outcome).

RESULTS
   Males (7/10), females (3/10), 4/10 (40%) died. Averaged age: 50. No abdominal aneurysm was found. Etiology-Site of rupture: pancreatic pseudoaneurysm (fig. 1), enphysematous pancreatitis (fig. 2), necrohemorrhagic pancreatitis (fig. 3), Wünderlich syndrome (fig. 4), aortic disection: celiac-trunk (fig. 5), (2) left iliac, massive rectus sheath haematoma (fig. 6), and 2 gynecological massive bleeding neoplasms (fig. 7): inmadure and malignant teratoma and sarcoma uterine.

Figure 1

Figure 2

Figure 3

Figure 4


Figure 5

Figure 6

Figure 7

    Hematoma extended into retroperitoneum in 40%, around pancreatic gland and perirrenal space, and mainly in pelvis in 60%. We identified active and the source of bleeding in all cases. Our results were confirmed by surgery.

DISCUSSION
   CT is the technique of choice for evaluating patients for whom a diagnosis of ruptured abdominal aortic aneurysm is being considered, they can be scanned rapidly while they are closely monitored. Hemorrhaged blood is usually easily identified in the retroperitoneum and is the clue of aortic rupture.

But, misdiagnosis is estimated in recent series in 4-20% of patients, leading to significant delays in treatment.
We would like to report with special attention our experience about pancreatic and other retroperitoneal diseases that simulated clinically this entity. CT is a highly accurate noninvasive method of evaluation the retroperitoneal pathology. Not only in the diagnosis of recognized complications of inflammatory diseases, such a severe pancreatitis, but also in the evaluation of the extent of the hematoma.

   Retroperitoneal hemorrhage may have been developed for a retroperitoneal bleeding mass such a gigant renal angiomyolipoma, Wünderlich syndrome, or a severe and atypical clinical presentation of an acute pancreatitis, which might have been involved the splenic vein, or a pseudoaneurysm secondary to chronic pancreatitis.

   CT also suggested that hemorrhage has not resulted from rupture of abdominal aortic aneurysm, the aortic margin was intact and the adjacent fat was preserved.

   The widespread of the hemorrhage may also suggest the source of bleeding, it may have been extended to the groin or to inguinal regions and the etiology may be a gynecological neoplasm or a rectus sheath haematoma.

CONCLUSION
   We believe that all patients hemodynamically stable with suspected ruptured abdominal aneurysm, in whom this diagnosis may be uncertain, would benefit from CT.

   A variety of retroperitoneal masses and pancreatic diseases in this location might have been confused with areas of aortic rupture. Also, retroperitoneal hemorrhage might have been developed for an unrelated reason.

   At an insular hospital is vital to know exactly and promptly the site and etiology of bleeding, in order to organize "the treatment equipment" in a more specialized center.

   The general surgeon and the radiologist must be prepared to respond rapidly, these patients may become unstable at any time.

REFERENCES

1. Siegel CL, Cohan RH. CT of abdominal aortic aneurys. AJR Am J Roentgenol 1994; 163: 17-29.

2. Siegel CL,et al. Abdominal aortic aneurysm morphology: CT features in patients with ruptured and nonruptured aneurysms. AJR Am J Roentgenol 1994; 163: 1123-1129.

 

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
Scientific Committee
President
Dr. Armando Pacher
Technical Committee - CETIFAC
President
fgaro@fac.org.ar
fgaro@satlink.com
rbretal@fac.org.ar
rbretal@netverk.com.ar
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