Thanks Stephanie for a great case. This is a young patient with a history of smoking meth and alcohol dependence coming in with acute abdominal pain, found to have ischemic bowel, leukocytosis and AKI ultimately diagnosed with a descending aortic dissection.
- ) Certain symptoms have a high positive likelihood ratio of thoracic aortic dissection including tearing/ ripping pain (LR+ 1.2-10.8) pulse deficits (LR+ 2.4-47) and focal neurologic deficits (LR+ 6.6-33) (JAMA 2002;287:2262-72)
- ) We discussed the utility of a D-dimer in diagnosis of aortic dissection. If < 500 ng/mL it has an excellent negative likelihood ratio (LR- 0.06) but not a good positive LR in a meta analysis (Am J Cardiol 2011;107(8):1227-34)
- ) “Trust but verify” This case involved a prolonged outside hospital stay prior to transfer and perhaps personal review of the primary data and imaging could have led to an earlier diagnosis.
Acute abdominal pain ddx
- Most common diagnoses include: acute pancreatitis, appendicitis, biliary pathology and functional
- Can’t miss include: dissection/ rupture/ aorto-enteric fistula/ infarct, and ischemia
- Other things to consider include: renal pathology, inferior MI, metabolic (eg DKA), ulcer, diverticulitis, hepatitis, PID/ gynecologic, rare infectious (eg endocarditis) or rheumatologic conditions (eg PAN), porphyria
- Vasculitis was on the differential for this patient with multi-organ injury secondary to some sort of vascular process; this case report has a nice chart that differentiates findings depending on the size of vessel involved in vasculitis
- Here is a great evidence-based review article on diagnosis and management of aortic dissections aimed at ER physicians
- The ACC/AHA has also published a 2010 algorithm along with guidelines on how to evaluate and manage a patient with an aortic dissection