Severe Abdominal Pain and Near Syncope in an Elderly

[Hani]

An 85-year-old man is presented to the emergency department (ED) by ambulance with severe abdominal pain that began suddenly 2 hours before presentation. The pain is mainly in his back and radiates toward his left inguinal region. The patient felt light-headed at the onset of the pain to the extent that he had to grip the sink to steady himself. He also reports significant nausea, although he has not vomited. He has no urinary symptoms. His medical history includes type 2 diabetes, hypertension, hyperlipidemia, ischemic heart disease, and intermittent claudication of his lower extremities. His medications include metformin, ramipril, simvastatin, aspirin, and a glyceryl trinitrate pump spray. He smoked 10-20 cigarettes a day for over 60 years but stopped 5 years ago.

The physical examination reveals tenderness in the left iliac fossa and left costovertebral angle. His vital signs are remarkable for a heart rate of 105 beats/min and a blood pressure of 110/90 mm Hg. The patient is prescribed further analgesia and 1 L of colloid is administered. He is then referred to the surgical assessment unit (SAU) as a case of possible ureteric colic, with an abdominal radiograph taken during transit (Figure 1). On arrival to the SAU, the patient and his abdominal film are reviewed by the on-call surgical doctor. After assessment of his airway, breathing, circulation, level of consciousness, and exposure for examination of his abdomen, oxygen is given via a face mask, intravenous access is obtained at 2 sites, and a urinary catheter is inserted. Blood is drawn for laboratory analysis, including blood urea nitrogen, electrolytes, a full blood count, coagulation panel, and cross matching. The patient's electrolytes, complete blood cell count, and coagulation panel result are unremarkable. Arterial blood gas analysis is obtained and reveals a metabolic acidosis. Intravenous fluids are continued and the patient is sent for an urgent CT scan of the abdomen. Once completed, he is transferred by ambulance to a regional center for immediate intervention

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Hint: Pay attention to the distribution of the pain and the history of presyncope at its onset, together with a careful review of the abdominal radiograph.

[einas]

this aortic aneurysm with calcified wall

[redoxe]

agree with einas

[husam alnaeem]

agreed with above answer + well dfinied opacity in bladder, osteoponea, osteoarthritic changes more on right

[Dr.Altayeb]

I think it's ureteric colic, although in the X-ray there is no apparent opacity but the distribution of the pain is typical of that of ureteric colic ,so it may be radio-lucent stone.In aortic calcification the there may appear retroperotineal calcification and its pain is radiated mainly to the back,but loin to groin radiation i think goes better with stone.

[hajalmahadi]

agreed with aortic aneurysm + bladder stone