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Dissecting Aneurysm of the Abdominal Aorta Simulating Renal Disease: A Case Diagnosed Ante-Mortem
THE JOURNAL OF UROLOGY
Vol. 65, No. 3, March 1951 Printed in U. S. A.
DISSECTING ANEURYSM OF THE ABDOMI~AL AORTA SIMULATING RENAL DISEASE: A CASE DIAGNOSED AXTE-MORTEM HENRY A. KONTOFF
AND
BERNARD R. SEARS
Rupture of a dissecting aneurysm of the aorta may give rise to symptoms and signs simulating urinary lithiasis and other urological lesions, such as perinephric abscess, infarct of the kidney and renal tumor. In cases where there is slow leakage of blood from the ruptured aneurysm, life may go on for \Yeeks and months before the fatal rupture occurs, but if the rent in the aneurysm is a large one, death occurs in 2 to 6 days. The most common causes of aneurysm are syphilis and arteriosclerosis. It is generally agreed that those of syphilitic origin usually occur in the arch and thoracic portion of the aorta and occur in the younger age groups, -while the aneurysms due to arteriosclerosis occur in the abdominal aorta and are usually of the dissecting type and present themselves in an older age group. The lesion is predominant in the male. The signs and symptoms direeting attention to the urinary tract arise from rupture into the retroperitoneal space or from occlusion or dissection of the walls of the renal artery; at times, secondary complete or partial thrombosis of the artery may also be present. The entire retroperitoneal space from the diaphragm to the pelvis may be distended with blood clot, causing displacement of important abdominal structures. When the hemorrhage into the perirenal area is sudden and massive, a flank mass may be found, together iYith tenderness, spasm, and a pulsation and bruit. Pressure on the nerve roots by the aneurysmal sac may also produce pain in the renal area. Classically, dissecting aneurysm of the aorta presents a striking clinical picture with pain, collapse, and manifestations of vascular compression as the dominant features. The onset is characterized by sudden abdominal pain, transient syncope, dyspnea, circulatory collapse and prostration. The pain, starting in the upper abdomen, flank, or midback, often radiates dmvmrnrd. Arterial compression may produce paraplegia, monoplegia, intestinal paresis, hematuria, and, at times, anuria. One or both femoral pulsations may be absent, sometimes returning after re-perforation into the arterial channel. Blood pressure may be elevated, -iow or at normal levels. Pallor and increasing anemia are present. There may be nausea and vomiting, fever, leukocytosis, and albuminuria. The blood picture is that of typical secondary anemia. The urological findings are varied. There may be impaired excretion of diodrast due to renal ischemic anoxia or due to interference ,vith urinary drainage by direct pressure of the hematoma on the pelvis or ureter. Often there is obliteration of the psoas shadmv. Depending on the quantity and distribution of the blood clot, the kidney may be rotated on its vertical or trans,"erse axis and displaced laterally, upward or dovrn,rnrd. There may be haziness or irregularity of the Read at the meeting, Xew England Section, American Urological Association, Boston, Mass., March 23, 1950. 364
DISSECTING ANEURYSM OF AORTA SIMULATING RENAL DISEASE
365
calyceal, pelvic or ureteral outline because of blood clot; a subsequent x-ray may show the disappearance of this abnormality if the clot has passed. Approximately 33 per cent of cases reported in the literature had hematuria. Hematuria usually signifies involvement of the renal artery. To recapitulate, the important signs and symptoms for consideration that are significant to the urologist in making a diagnosis of dissecting aneurysm of the abdominal aorta are: 1) Sudden pain in the upper abdomen, flank, or mid back. This pain is constant and does not appreciably yield to the ordinary opiates. 2) Faintness, pallor and increasing anemia which are not improved with repeated blood transfusions. 3) Urographic changes that are usually seen in the malposition of the kidney and ureter, impaired function of the kidney, and obliteration of the psoas margin. 4) Loin mass that has a pulsation and bruit. CASE REPORT
No. 23584, Orin K., a 70 year old retired rivet maker, entered the hospital with the chief complaint of severe left back and flank pain. Two days before admission, while seated in his bath tub and bending forward to wash his feet, the patient felt "something snap" with a sudden sharp pain in his left back. The pain was so severe that he could not leave the tub without assistance. His family physician strapped his back with adhesive tape, believing the patient had strained his back muscles. Four hours later the pain radiated to the left flank and abdomen. Seven hours after the initial attack of pain his abdomen became distended. He had no nausea but vomited once. The patient had episodes of extreme weakness. Because of the abdominal distention, extreme weakness and increase in back and flank pain, the patient was hospitalized. The past history was essentially negative except for infectious diseases of childhood, He had had no operations or accidents. System review revealed that his blood pressure was 160/80 for the past few years. There were no urinary symptoms. Physical examination revealed a well developed and well nourished white man, with pallor of his skin and in some discomfort. The temperature was 98F, pulse 98, respirations 20, blood pressure 125/70. Head, neck, heart, and lungs were not remarkable. The abdomen was distended and tympanitic throughout, no masses felt nor abnormal sounds heard by stethoscope. The patient complained of tenderness to palpation in the left upper quadrant of the abdomen, left flank, and left costovertebral angle. Neither kidney could be felt. The genitalia were normal. The rectal examination revealed the prostate to be normal in size and consistency. The laboratory reported the urine clear; pH 5.5; albumin negative; sugar negative; acetone negative; bile negative; sediment showed a few white blood cells and occasional red blood cells per high power field and uric acid crystals. Red blood cells 2,900,000; white blood cells 20,000; hemoglobin 53 per cent (7.7 gm. per cent). Polymorphonuclears 81 per cent; lymphocytes 13 per cent:
366
HENRY A. KONTOFF AND BERNARD R. SEARS
stabs 6 per cent, achromia of red blood cells. Hinton and Kahn tests negative. The plain x-ray of the abdomen showed "the entire colon dilated with gas and with considerable amount of fecal material in the ascending colon. The kidney outlines were obscured by intestinal shadows. There was an opacity overlying the region of the left kidney that might represent a renal calculus." For 36 hours after admission, the patient was given sedatives but they gave only temporary relief and the pain persisted in the left costovertebral angle, left flank and finally radiated to the lower left abdomen. Repeated enemas did not relieve the abdominal distention. The patient ate his meals without nausea or
Fm. 1. A, plain x-ray with ureteral catheters in place revealing lateral displacement of upper two thirds of left ureter. B, retrograde pyelograms reveal normal architecture of both kidneys. Left kidney is displaced upward and laterally and upper left ureter is displaced laterally by a large retroperitoneal tumor.
vomiting. The hospital staff considered the diagnosis of left renal calculus and asked for a urological consultation. Cystoscopic examination revealed the bladder mucosa to be normal throughout; no stones, tumor or diverticula seen. A No. 5 catheter passed up both ureters without meeting obstruction and there was clear flow of urine from each kidney. A plain x-ray (fig. 1, A) showed marked lateral displacement of the upper two thirds of the left ureter. No calculi were seen in the urinary tract. The retrograde pyelogram (fig. 1, B) showed the calyces and pelves of both kidneys to be normal in outline. The position of the right kidney and ureter was normal. The left kidney was displaced upward and to the left. The upper two thirds of the left ureter was displaced about 6 cm. laterally by a large retroperitoneal mass. A diagnosis of rupture of a dissecting aneurysm of the abdominal aorta was made.
DISSECTING ANEURYSM OF AORTA SIMULATING RENAL DISEASE
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Whole blood and plasma were given without any appreciable gain in the blood count. No amount of sedation seemed to relieve the patient of pain which seemed to increase in severity. On the third day after admission to the hospital, the patient suddenly complained of excruciating pain in left lower quadrant of his abdomen, went into shock and died within a few minutes. On post mortem examination "the aorta shows marked calcification. Midway between the diaphragm and the bifurcation of the iliac vessels, there is an area of rupture. The aorta adjacent to the area of rupture measures 8.5 cm. in diameter, and there is a dissecting aneurysm in this region, which condition has existed for a long period of time, evidenced by laminated clot in the aneurysmal sac. The aneurysm has ruptured on the left side and there is a massive hemorrhage into the left retroperitoneal tissues." SUMMARY
A review is made of the clinical picture of dissecting aneurysm of the abdominal aorta, with special reference to manifestations directing attention to the urinary tract. A case, diagnosed ante-mortem by means of urological study, is reported. 483 Beacon St., Boston, Mass. REFERENCES BAUERSFELD, S. R.: Ann. Int. Med., 26: 873, 1947. BLAKEMORE, A.H.: Ann. Surg., 126: 195, 1947. BLAIN, A. AND GLYNN, T. P.: J. Ural., 63: 753, 1945. BucKLEY, T. L.: J. Ural., 44: 816, 1940. DAVID, P. et al.: Ann. Int. Med., 27: 405, 1947. GREENE, L. F.: J. Ural., 59: 174, 1948. LAZARUS, J. A. AND MARKS, M. S.: J. Ural., 52: 115, 1944. PERRY, T. M.: Am. Heart J., 12: 650, 1936. SCHULTE, T. L. AND EMMETT, J. L.: J. Ural., 42: 215, 1939. SWEETSER, T. H.: J. Ural., 47: 619, 1941. UHLE, C. A. W.: J. Ural., 45: 13, 1941.
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Vol. 65, No. 3, March 1951 Printed in U. S. A.
DISSECTING ANEURYSM OF THE ABDOMI~AL AORTA SIMULATING RENAL DISEASE: A CASE DIAGNOSED AXTE-MORTEM HENRY A. KONTOFF
AND
BERNARD R. SEARS
Rupture of a dissecting aneurysm of the aorta may give rise to symptoms and signs simulating urinary lithiasis and other urological lesions, such as perinephric abscess, infarct of the kidney and renal tumor. In cases where there is slow leakage of blood from the ruptured aneurysm, life may go on for \Yeeks and months before the fatal rupture occurs, but if the rent in the aneurysm is a large one, death occurs in 2 to 6 days. The most common causes of aneurysm are syphilis and arteriosclerosis. It is generally agreed that those of syphilitic origin usually occur in the arch and thoracic portion of the aorta and occur in the younger age groups, -while the aneurysms due to arteriosclerosis occur in the abdominal aorta and are usually of the dissecting type and present themselves in an older age group. The lesion is predominant in the male. The signs and symptoms direeting attention to the urinary tract arise from rupture into the retroperitoneal space or from occlusion or dissection of the walls of the renal artery; at times, secondary complete or partial thrombosis of the artery may also be present. The entire retroperitoneal space from the diaphragm to the pelvis may be distended with blood clot, causing displacement of important abdominal structures. When the hemorrhage into the perirenal area is sudden and massive, a flank mass may be found, together iYith tenderness, spasm, and a pulsation and bruit. Pressure on the nerve roots by the aneurysmal sac may also produce pain in the renal area. Classically, dissecting aneurysm of the aorta presents a striking clinical picture with pain, collapse, and manifestations of vascular compression as the dominant features. The onset is characterized by sudden abdominal pain, transient syncope, dyspnea, circulatory collapse and prostration. The pain, starting in the upper abdomen, flank, or midback, often radiates dmvmrnrd. Arterial compression may produce paraplegia, monoplegia, intestinal paresis, hematuria, and, at times, anuria. One or both femoral pulsations may be absent, sometimes returning after re-perforation into the arterial channel. Blood pressure may be elevated, -iow or at normal levels. Pallor and increasing anemia are present. There may be nausea and vomiting, fever, leukocytosis, and albuminuria. The blood picture is that of typical secondary anemia. The urological findings are varied. There may be impaired excretion of diodrast due to renal ischemic anoxia or due to interference ,vith urinary drainage by direct pressure of the hematoma on the pelvis or ureter. Often there is obliteration of the psoas shadmv. Depending on the quantity and distribution of the blood clot, the kidney may be rotated on its vertical or trans,"erse axis and displaced laterally, upward or dovrn,rnrd. There may be haziness or irregularity of the Read at the meeting, Xew England Section, American Urological Association, Boston, Mass., March 23, 1950. 364
DISSECTING ANEURYSM OF AORTA SIMULATING RENAL DISEASE
365
calyceal, pelvic or ureteral outline because of blood clot; a subsequent x-ray may show the disappearance of this abnormality if the clot has passed. Approximately 33 per cent of cases reported in the literature had hematuria. Hematuria usually signifies involvement of the renal artery. To recapitulate, the important signs and symptoms for consideration that are significant to the urologist in making a diagnosis of dissecting aneurysm of the abdominal aorta are: 1) Sudden pain in the upper abdomen, flank, or mid back. This pain is constant and does not appreciably yield to the ordinary opiates. 2) Faintness, pallor and increasing anemia which are not improved with repeated blood transfusions. 3) Urographic changes that are usually seen in the malposition of the kidney and ureter, impaired function of the kidney, and obliteration of the psoas margin. 4) Loin mass that has a pulsation and bruit. CASE REPORT
No. 23584, Orin K., a 70 year old retired rivet maker, entered the hospital with the chief complaint of severe left back and flank pain. Two days before admission, while seated in his bath tub and bending forward to wash his feet, the patient felt "something snap" with a sudden sharp pain in his left back. The pain was so severe that he could not leave the tub without assistance. His family physician strapped his back with adhesive tape, believing the patient had strained his back muscles. Four hours later the pain radiated to the left flank and abdomen. Seven hours after the initial attack of pain his abdomen became distended. He had no nausea but vomited once. The patient had episodes of extreme weakness. Because of the abdominal distention, extreme weakness and increase in back and flank pain, the patient was hospitalized. The past history was essentially negative except for infectious diseases of childhood, He had had no operations or accidents. System review revealed that his blood pressure was 160/80 for the past few years. There were no urinary symptoms. Physical examination revealed a well developed and well nourished white man, with pallor of his skin and in some discomfort. The temperature was 98F, pulse 98, respirations 20, blood pressure 125/70. Head, neck, heart, and lungs were not remarkable. The abdomen was distended and tympanitic throughout, no masses felt nor abnormal sounds heard by stethoscope. The patient complained of tenderness to palpation in the left upper quadrant of the abdomen, left flank, and left costovertebral angle. Neither kidney could be felt. The genitalia were normal. The rectal examination revealed the prostate to be normal in size and consistency. The laboratory reported the urine clear; pH 5.5; albumin negative; sugar negative; acetone negative; bile negative; sediment showed a few white blood cells and occasional red blood cells per high power field and uric acid crystals. Red blood cells 2,900,000; white blood cells 20,000; hemoglobin 53 per cent (7.7 gm. per cent). Polymorphonuclears 81 per cent; lymphocytes 13 per cent:
366
HENRY A. KONTOFF AND BERNARD R. SEARS
stabs 6 per cent, achromia of red blood cells. Hinton and Kahn tests negative. The plain x-ray of the abdomen showed "the entire colon dilated with gas and with considerable amount of fecal material in the ascending colon. The kidney outlines were obscured by intestinal shadows. There was an opacity overlying the region of the left kidney that might represent a renal calculus." For 36 hours after admission, the patient was given sedatives but they gave only temporary relief and the pain persisted in the left costovertebral angle, left flank and finally radiated to the lower left abdomen. Repeated enemas did not relieve the abdominal distention. The patient ate his meals without nausea or
Fm. 1. A, plain x-ray with ureteral catheters in place revealing lateral displacement of upper two thirds of left ureter. B, retrograde pyelograms reveal normal architecture of both kidneys. Left kidney is displaced upward and laterally and upper left ureter is displaced laterally by a large retroperitoneal tumor.
vomiting. The hospital staff considered the diagnosis of left renal calculus and asked for a urological consultation. Cystoscopic examination revealed the bladder mucosa to be normal throughout; no stones, tumor or diverticula seen. A No. 5 catheter passed up both ureters without meeting obstruction and there was clear flow of urine from each kidney. A plain x-ray (fig. 1, A) showed marked lateral displacement of the upper two thirds of the left ureter. No calculi were seen in the urinary tract. The retrograde pyelogram (fig. 1, B) showed the calyces and pelves of both kidneys to be normal in outline. The position of the right kidney and ureter was normal. The left kidney was displaced upward and to the left. The upper two thirds of the left ureter was displaced about 6 cm. laterally by a large retroperitoneal mass. A diagnosis of rupture of a dissecting aneurysm of the abdominal aorta was made.
DISSECTING ANEURYSM OF AORTA SIMULATING RENAL DISEASE
367
Whole blood and plasma were given without any appreciable gain in the blood count. No amount of sedation seemed to relieve the patient of pain which seemed to increase in severity. On the third day after admission to the hospital, the patient suddenly complained of excruciating pain in left lower quadrant of his abdomen, went into shock and died within a few minutes. On post mortem examination "the aorta shows marked calcification. Midway between the diaphragm and the bifurcation of the iliac vessels, there is an area of rupture. The aorta adjacent to the area of rupture measures 8.5 cm. in diameter, and there is a dissecting aneurysm in this region, which condition has existed for a long period of time, evidenced by laminated clot in the aneurysmal sac. The aneurysm has ruptured on the left side and there is a massive hemorrhage into the left retroperitoneal tissues." SUMMARY
A review is made of the clinical picture of dissecting aneurysm of the abdominal aorta, with special reference to manifestations directing attention to the urinary tract. A case, diagnosed ante-mortem by means of urological study, is reported. 483 Beacon St., Boston, Mass. REFERENCES BAUERSFELD, S. R.: Ann. Int. Med., 26: 873, 1947. BLAKEMORE, A.H.: Ann. Surg., 126: 195, 1947. BLAIN, A. AND GLYNN, T. P.: J. Ural., 63: 753, 1945. BucKLEY, T. L.: J. Ural., 44: 816, 1940. DAVID, P. et al.: Ann. Int. Med., 27: 405, 1947. GREENE, L. F.: J. Ural., 59: 174, 1948. LAZARUS, J. A. AND MARKS, M. S.: J. Ural., 52: 115, 1944. PERRY, T. M.: Am. Heart J., 12: 650, 1936. SCHULTE, T. L. AND EMMETT, J. L.: J. Ural., 42: 215, 1939. SWEETSER, T. H.: J. Ural., 47: 619, 1941. UHLE, C. A. W.: J. Ural., 45: 13, 1941.
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