Ultrasound Case 056

Presentation

You take handover of an 84 year old man with presumed right-sided renal colic awaiting a CT KUB. You are called, he has suddenly deteriorated. On review you find his pain has worsened and he is pale, sweaty and hypotensive.

Is this a vagal response to pain, a reaction to his analgesia or something else? You scan his aorta.


View 2

Describe and interpret these scans

IMAGE INTERPRETATION

Image 1 & 2: Transverse views of the abdominal aorta. The aorta is aneurysmal measuring about 10cm in diameter. There is intraluminal lamellated thrombus against the posterolateral and left aortic wall.

Acute predominantly hypoechoic retroperitoneal haemorrhage is seen anteriorly and to the right of the aorta – causing what was initially thought to be right-sided renal colic.

LITFL Top 100 Ultrasound 056 01 Acute AAA Image Key
Key to Images 1 & 2.

CLINICAL CORRELATION

Ruptured abdominal aortic aneurysm with retroperitoneal haematoma

As an abdominal aortic aneurysm slowly expands it is common for layers of thrombus to form against the inner surface of the aneurysmal wall.

Whilst ultrasound can readily measure the size of the aorta and hence detect an aortic aneurysm, it cannot reliably exclude the presence of a leak or rupture. It can sometimes confirm rupture if retroperitoneal haematoma is detected. This tends to dissect retroperitoneally toward the left, often displacing the left kidney inferolaterally.

On this occasion blood tracked to the right mimicking right-sided renal colic. The blood seen here is hyperacute and has not yet clotted completely – much of it still appears hypoechoic and liquid – it appears to flow as the adjacent aorta pulsates.


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An Emergency physician based in Perth, Western Australia. Professionally my passion lies in integrating advanced diagnostic and procedural ultrasound into clinical assessment and management of the undifferentiated patient. Sharing hard fought knowledge with innovative educational techniques to ensure knowledge translation and dissemination is my goal. Family, wild coastlines, native forests, and tinkering in the shed fills the rest of my contented time. | SonoCPDUltrasound library | Top 100 | @thesonocave |

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