COTW 6/24: A 63 year old male with abdominal pain

A 63 year old male with no known past medical history presents to the ED with abdominal pain. Patient’s son reports that he was lifting a tire when he had sudden onset abdominal pain, became diaphoretic, pale, and was pre-syncopal. Initial blood pressure is 98/68.

Point of care ultrasound of the abdomen was performed:

Point of care ultrasound of the abdomen revealed a heterogenous mass in the mid epigastrium and RUQ, distinct from the liver, kidney, and aorta. A strip of anechoic fluid was noted in the far field, between the mass and the aorta and right kidney.

The mass and anechoic fluid in the peritoneum were concerning for blood and hematoma. The main concern at presentation was a ruptured abdominal aortic aneurism, though a normal caliber aorta was noted and the free fluid and hematoma were noted to be in the peritoneal cavity; a ruptured AAA would be located in the retroperitoneum. While the ultrasonographic findings were less consistent with a ruptured AAA, they were highly concerning for a vascular catastrophe and the patient underwent emergent abdominal CTA.

CTA showed a large hematoma (black arrows) with a pancreaticoduodenal artery (PDA) aneurism rupture (white arrow). The patient was taken emergently to interventional radiology where he underwent endovascular glue embolization of the PDA. Hemoglobin drawn at initial presentation was 14.2 and on repeat was 7.5. Patient received 4 units of packed red cells for acute blood loss anemia but tolerated the procedure well, had no signs of rebleeding, and was discharged home three days later in stable condition.