By Tedler D. Depaynos, MD
The 68 years old male patient was a farmer in a nearby province. For the past years he could feel a pulsating mass on the left side of his abdomen. Because he was not feeling anything, he just tolerated it. After many years, he felt that the pulsation was getting stronger or even superficial so that eventually, his children could visualize the pulsations. They felt a mass their father claimed to have been getting stronger, but again because it was symptomless, no consultations was ever done.
It was after a year or two when suddenly he felt severe pain over the left side of his abdomen which was even radiating to his back. Because of the severe pain, he finally consented to be brought to the hospital.
At the emergency room (ER), the MDs on duty easily felt the pulsating mass. It was initially thought of as a colonic mass being anteriorly pushed regularly by the pulsating “aorta” which is the huge blood vessel from the heart coming down through the abdominal cavity supplying the lower extremities. After a careful examination, however, the impression was changed into a pulsating “aortic aneurysm”. This was confirmed by a simple plain ultrasound (UTZ) of the abdomen.
An “aneurysm” is a bulging of a portion of the wall of an artery due to weakness and the internal pressure originating from the heart. It could be due to a previous trauma, infection or other diseases affecting the blood vessel. It could be congenital and because of age it finally gave way which resulted into the localized dilatation of the blood vessel. This may be the cause in this patient’s aneurysm.
Aneurysm is usually painless unless there is ‘dissection”. Part of the arterial wall may be damaged due to excessive dilatation and the blood may dissect inside the walls of the artery hence causing severe pain. This may increase the weakness of the “aneurysm” and the possibility of rupture is more than doubled. This was highly entertained by the examining MDs. When they noticed the patient to be looking pale and anemic which was confirmed by his complete blood count (CBC) results, the possibility of blood oozing from the “dissected aneurysm” was highly considered even if the UTZ revealed no abdominal fluid.
The unfortunate possibility of rupture was explained to the patient’s relatives and a referral to a Vascular Surgeon was immediately made. The surgeon recommended that a dye would be injected that would eventually go into the aorta and with the use of CT Scan, the aneurysm would clearly be visualized so that what kind of surgery would be done would be discussed. Meanwhile, an aggressive lowering of the patient’s blood pressure was done and the patient was made to relax completely. Even a laxative was prescribed so that no abdominal pressure would be stimulated while defecating. Abdominal examination by palpation was also prohibited.
The patient was silent with his eyes closed while waiting for the CT Scan procedure when suddenly he began to vomit and complained of pain in his abdomen. He suddenly stopped breathing so that an emergency resuscitation was done. Although it was initially successful, a repeat procedure was done and after sometime the relatives decided and requested that it would be discontinued. They were able to talk to the patient however before his last breath because the last sense to disappear is the sense of hearing. Even if the patient was unconscious, he could still hear what they were saying with their tears profusely flowing down.
In retrospect, an asymptomatic “aneurysm” could easily be remedied by Vascular Surgeons. It was very unfortunate that the patient waited for the “dissection” to occur before coming for consultation which the relatives greatly regretted.**
