Sanjana Sanghani, Gerald Tolbert, Rachna Subramony
A 52-year-old male with a past medical history significant for hypertension and hyperlipidemia presented to the Emergency Department with two days of intermittent chest discomfort accompanied by mild epigastric pain. The pain was non-radiating, episodic, and not associated with nausea, vomiting, diaphoresis, syncope, or exertion. He denied recent trauma, heavy lifting, or prior similar episodes. There was no known personal history of vascular disease, tobacco use, or family history of aneurysmal disease.
An electrocardiogram demonstrated normal sinus rhythm without ischemic changes.
Vital Signs: BP 148/92 mmHg | HR 78 | T 98.1°F | RR 18 | SpO2 98% on room air
The patient appeared comfortable and in no acute distress. Cardiopulmonary examination was unremarkable, with normal heart sounds and clear lung fields. Abdominal examination revealed mild tenderness to deep palpation in the epigastric region without guarding, rebound tenderness, or palpable pulsatile mass. No abdominal bruits were auscultated. Peripheral pulses were symmetric and intact in all extremities, and there were no focal neurologic deficits.
Given the patient’s nonspecific symptoms, elevated blood pressure, and underlying cardiovascular risk factors, a point-of-care abdominal aortic ultrasound was performed to evaluate for occult aortic pathology. Bedside ultrasound examination of the abdominal aorta was performed using a low-frequency (2–5 MHz) curvilinear transducer. The aorta was evaluated in both transverse and longitudinal planes from the epigastrium to the aortic bifurcation, with measurements obtained from outer wall to outer wall, as recommended by established ultrasound guidelines.
No free intraperitoneal fluid was identified on the focused abdominal assessment.
Discussion
Abdominal aortic aneurysm (AAA) is defined as a focal dilation of the abdominal aorta measuring ≥3.0 cm in maximal diameter or greater than 50% of the expected normal diameter. AAAs are most commonly infrarenal and fusiform in morphology, though saccular aneurysms—characterized by asymmetric outpouching—are less common and may be associated with higher rupture risk depending on etiology and size.
Point-of-care ultrasound (POCUS) is a highly effective, rapid, and noninvasive modality for the detection of AAA in the emergency department. Numerous studies have demonstrated that emergency physician–performed ultrasound has a sensitivity approaching 99% and specificity of approximately 98% for identifying AAA. This high diagnostic accuracy makes POCUS a first-line imaging tool, particularly in patients with atypical presentations, vague abdominal or chest symptoms, or when rapid risk stratification is required.
Importantly, AAA can present with nonspecific symptoms such as epigastric pain, back pain, or chest discomfort, and classic findings, such as hypotension or a palpable pulsatile mass, are often absent. Early identification using bedside ultrasound allows for prompt vascular surgery consultation and expedited confirmatory imaging, typically with CT angiography in hemodynamically stable patients.
Ultrasound evaluation focuses on identifying aneurysmal dilation, assessing morphology, and measuring maximal diameter. The presence of mural thrombus, commonly seen within AAAs, does not by itself indicate rupture but may be associated with embolic complications. While POCUS excels at identifying aneurysm presence and size, it has limitations: it cannot reliably assess suprarenal extension, branch vessel involvement, or small contained ruptures. Additionally, ultrasound is not sufficient to exclude acute aortic dissection or retroperitoneal hemorrhage, for which CT angiography remains the gold standard.
In this case, although the patient was hemodynamically stable and lacked classic symptoms of rupture, bedside ultrasound facilitated early recognition of significant aortic pathology that may have otherwise been delayed due to the nonspecific nature of his presentation.
Conclusion
This case underscores the critical role of point-of-care ultrasound in the emergency evaluation of patients with vague chest or abdominal symptoms and cardiovascular risk factors. Rapid bedside identification of an abdominal aortic aneurysm enabled early diagnosis, appropriate risk stratification, and timely specialty referral. POCUS remains an indispensable diagnostic adjunct in emergency medicine, particularly for the detection of life-threatening aortic pathology.
References
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