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Case 251

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A 75-year-old male patient living in a rural area, admitted to the emergency department with complaints of abdominal pain, mainly in the right iliac fossa, progressive, of high intensity, without irradiation, without signs of peritoneal irritation, with a few hours duration . It reports controlled systemic arterial hypertension and treated prostate neoplasia. Computed tomography of the abdomen and pelvis without contrast medium and angiotomography of the aorta and iliac arteries were performed for diagnostic confirmation.

Based on the clinical presentation and images presented, the most likely diagnosis is:

a) Rupture iliac artery aneurysm.

25%

b) Intra abdominal foreign body.

25%

c) Dissection of iliac artery.

25%

d) Mesenteric ischemia.

25%
   

Image analysis

Image 1: Computed tomography of the pelvis, axial section, without contrast medium. Presence of atheromatous calcifications in topography of iliac arteries (red arrows). There is evidence of a diametrical increase of the right iliac artery.

 

 

Image 2: Abdominal and pelvic computed tomography, coronal reconstruction, without contrast medium. Presence of atheromatous calcifications in the aortic bifurcation and in the iliac arteries, evidencing evidence of a diametrical increase of the right iliac artery.

 

Image 3: Computed tomography of the pelvis, axial section, after intravenous administration of iodinated contrast medium - angiotomography. Saccular aneurysm dilatation at the medial border of the right common iliac artery, as well as segmental fusiform dilatation at the distal portion of the left common iliac artery (in red).

 

Image 4: Abdominal and pelvic computed tomography, coronal reconstruction, after intravenous administration of iodinated contrast medium - angiotomography. Tortuous abdominal aorta. Presence of atheromatous calcifications in the aortic bifurcation and in the iliac arteries, as well as in mesenteric branches. Saccular aneurysm dilatation at the medial border of the right common iliac artery (red), with local contrast medium extravasation (yellow circle) as well as segmental fusiform dilatation at the distal portion of the left common (green) iliac artery.

Highlights

- Aneurysms are focal and permanent dilations of arteries, with an increase of more than 50% of the original diameter.
- The main risk factors for AAI are: advanced age, male gender, smoking, and positive family history of aneurysm.
- Most aneurysms are asymptomatic. Symptoms when present are severe abdominal pain or low back pain.
- Clinical data do not allow diagnostic confirmation and imaging is necessary.
- It is suggested that abdominal aneurysms should be screened in men older than 65 years.
- Treatment of the aneurysm can be surgical or conservative and depends on the diameter and symptomatology.

References

- Moll FL, Powell JT, Fraedrich G, Verzini F, Haulon S, Waltham M, van Herwaarden JA, Holt PJ, van Keulen JW, Rantner B, Schlösser FJ, Setacci F, Ricco JB. Management of abdominal aortic aneurysms. Clinical practice guidelines of the European Society for Vascular Surgery. Eur J VascEndovascSurg 2011;41Suppl 1:S1-S58.

- Kirkwood ML. Iliac artery aneurysm.UpToDate [Internet] 2015 [acesso em setembro 2016]. Disponível em:https://www.uptodate.com/contents/iliac­artery­aneurysm/print?source=search_result&search=iliac%20aneurysm&selectedTitle=1~36.

- Jeffrey J, Thompson RW. Clinical features and diagnosis of abdominal aortic aneurysm. UpToDate [Internet] 2015 [acesso em setembro 2016]. Disponível em: http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-abdominal-aortic-aneurysm

- Sociedade Brasileira de Angiologia e Cirurgia Vascular. Projeto Diretrizes: aneurisma de aorta abdominal, diagnóstico e tratamento. 2015.

-Hands, L e Thompson M. Oxford specialist hand books in surgery: Vascular Surgery. 2ed. Oxford, Reino Unido. Oxford University Press. 2015.

Authors

Ana Carina Breunig Nunes, 6th year medical student at Faculdade de Medicina da UFMG.

E-mail: anacbreunig[arroba]gmail.com

Supervisor

Dr. Rafael Henrique Rodrigues Costa, Vascular Surgeon Doctor, Hospital Evagélico de Belo Horizonte.
E-mail: rafacosta [at] msn.com

Reviewers

Fernando Bottega, Cairo Mendes, Prof José Nelson Vieira e Profª Viviane Parisotto

Translated by:

Daniele Araújo Pires, 6th year studentent at Faculdade de Medicina da UFMG.

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