General Surgery Rotation

General Surgery: Aortic aneurysm/dissection

Patient will present as → a 73-year-old female with a history of hypertension, diabetes, and coronary artery disease who presents to the emergency department with severe, tearing, knife-like back pain. She states that the pain started approximately 30 minutes ago and she has felt lightheaded and dizzy ever since its onset. On exam, her vitals are given: T: 98.6 F, HR: 115 bpm, BP: 95/53, RR: 14, SaO2: 97% on room air. An abdominal CT with contrast is obtained and is demonstrated here.

A patient presents to the ER with tearing chest pain radiating to his back. What is the most likely diagnosis?
Aortic dissection

Abdominal Aortic Aneurism (AAA) = back pain, pulsatile mass, and hypotension

Dissection = severe, tearing (ripping, knife-like) chest pain radiating to the back

Abdominal Aortic Aneurysm

Presentation: Flank pain, hypotension, pulsatile abdominal mass

  • Screening: Ultrasound, if male >65 and ever a smoker
  • Surgical repair if >5.5 cm or expands >0.6 cm per year
  • Monitor annually if >3 cm. Monitor every 6 months if >4 cm
  • Beta-blocker

  • The classic presentation is an older male (>60y) with severe back or abdominal pain who presents with syncope and hypotension with a tender pulsatile abdominal mass. 
  • Unlike dissection, an AAA involves all 3 layers
  • Males are eight times as likely to have an aortic aneurysm.
  • > 3.0 cm is usually considered aneurysmal
  • Diagnosed by ultrasound CT scan test of choice for further eval
  • Treatment is based on size - see "treatment" section

Aortic Dissection

Presentation: Sudden onset tearing chest pain, between scapulas.Diminished pulses

  • Chest radiograph: Widened mediastinum
  • Ascending aorta- Surgical emergency
  • Descending aorta- Medical therapy (beta blockers) unless complications are present

  • Aortic Dissection is caused by hypertension and involves only one layer of the arterial lining (the intima)
  • Patient will present with SEVERE, TEARING (RIPPING, KNIFE LIKE) sensation radiating to the back
  • Variation in pulse between the right and the left arm
  • MRI angiography is the gold standard for evaluation
  • Treatment
    • Lower Blood pressure
    • Type A (Proximal Aortic Dissection)
      • Surgical management
    • Type B (Distal Aortic Dissection)
      • Medical management initially, surgery only if needed
What will a CXR show for a patient with an aortic dissection?
Widened mediastinum

AAA - ultrasound is the initial imaging study of choice, CT scan is the test of choice for thoracic aneurysms and for further evaluation of patients with known AAA

  • Angiography is GOLD STANDARD for evaluation of AAA
  • Screening: The USPSTF recommends one-time screening for abdominal aortic aneurysm by ultrasonography in men ages 65 to 75 years who have ever smoked

Aortic Dissection: MRI Angiography is the gold standard for evaluation

Management of AAA

  • No further testing if aorta < 3.0 cm diameter
  • Repeat US yearly if aorta 3.0 – 4.4 cm
  • Repeat US every 6 months if aorta 4.5 – 5.0 cm
    • Referral to vascular surgery at this stage
  • Repeat US every 3 months if aorta 5-5.4 com
  • > 5.5 or > 0.5 cm expansion in 6 months - Immediate surgical repair (even if asymptomatic)

Management of Dissection

  • Lower Blood pressure
  • Type A (Proximal Aortic Dissection)
    • Surgical management
  • Type B (Distal Aortic Dissection)
    • Medical management initially, surgery only if needed


osmosis Osmosis
Abdominal aortic aneurysms


Abdominal aortic aneurysms are described as dilatations or outpouchings of the endothelial walls of the descending aorta. Rupture of these aneurysms are life-threatening, and patients who have ever smoked between the ages of 65 and 70 should be screened. The diagnostic treatment of choice is ultrasound, and treatment recommendations are as follows: aneurysms which are less than 5 centimeters and asymptomatic should be observed; aneurysms greater than 5.5 centimeters should be surgically repaired; ruptured or symptomatic aneurysms require emergent intervention.

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Aortic Dissection

Aortic dissection is a potentially catastrophic condition initiated by a tear in the aortic intima. There are 2 systems used to classify aortic dissections: Stanford and DeBakey. Under the Stanford classification, type A dissections occur in the ascending aorta while type B dissections are all others. Risk factors include hypertension, aortic aneurysm, and connective tissue disorders like Marfan syndrome. Clinical features of this disease include sudden, severe chest pain that may radiate to the back, blood pressure difference between upper extremities, and mediastinal widening on chest X-ray. Treatment includes surgery for Type A as they carry a risk of dissecting proximally into the pericardium and heart valves. Type B dissections are managed with beta blockers to reduce blood pressure.

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Question 1
A 60-year-old male is brought to the ED complaining of severe onset of chest pain and interscapular pain. The patient states that the pain feels as though "something is ripping and tearing". The patient appears shocky; the skin is cool and clammy. The patient has an impaired sensorium. Physical examination reveals a loud diastolic murmur and variation in blood pressure between the right and left arm. Based on this presentation what is the most likely diagnosis?
Aortic dissection
Acute myocardial infarction
See A for explanation.
Cardiac tamponade
See A for explanation.
Pulmonary embolism
See A for explanation.
Question 1 Explanation: 
The scenario presented here is typical of an ascending aortic dissection. In an acute myocardial infarction the pain builds up gradually. Cardiac tamponade may occur with a dissection into the pericardial space; syncope is usually seen with this occurrence. Pulmonary embolism is usually associated with dyspnea along with chest pain.
Question 2
What type of chest pain is most commonly associated with a dissecting aortic aneurysm?
Squeezing pain is more characteristic of angina or esophageal pain.
Dull, aching
Dull, aching pain is more characteristic of chest wall pain, possibly angina, or anxiety.
Ripping, tearing
Burning pain is more characteristic of esophageal reflux, esophagitis, or tracheobronchitis.
Question 2 Explanation: 
A dissecting aortic aneurysm often presents with a very severe ripping, tearing-like pain.
There are 2 questions to complete.
Shaded items are complete.
General Surgery: Chest pain; history of angina (Prev Lesson)
(Next Lesson) General Surgery: Dyspnea on exertion
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