The document discusses ruptured aneurysms of the aorta, specifically focusing on ruptured abdominal aortic aneurysms (RAAAs). It describes the typical presentation of RAAAs, which includes abdominal or back pain, hypotension, and the potential presence of a pulsatile abdominal mass. It notes that RAAAs have a high mortality rate if not treated emergently through open repair or potentially endovascular aneurysm repair (EVAR). Unusual presentations of RAAAs are also discussed, which can include symptoms like leg paralysis or groin/testicular pain that mimic other conditions and delay diagnosis.
one of most important topic of vascular surgery , i couldn't find this much in slideshare so , i made a slide and uploaded it . Hope you will enjoy reading :)
Definitions of GI bleeding
GI Bleeding include Upper and Lower of GIB
Causes of GI bleeding
Pathogenesis of GI bleeding
Diagnosis of GI bleeding
Clinical of GI bleeding
Management of GI bleeding
Recommendation of GI bleeding
Clinical guideline of GI bleeding
one of most important topic of vascular surgery , i couldn't find this much in slideshare so , i made a slide and uploaded it . Hope you will enjoy reading :)
Definitions of GI bleeding
GI Bleeding include Upper and Lower of GIB
Causes of GI bleeding
Pathogenesis of GI bleeding
Diagnosis of GI bleeding
Clinical of GI bleeding
Management of GI bleeding
Recommendation of GI bleeding
Clinical guideline of GI bleeding
What is Lymphoma?
Malignant lymphoma is a term given to tumors of the lymphoid system and specifically of lymphocytes and their precursor cells
i.e.
Cancer of the lymphatic system.
Many lymphomas are known to be due to specific genetic mutations.
USMLE CVS 005 Blood vessels – Arteries and veins.pdfAHMED ASHOUR
The major blood vessels in the human body form an extensive network that facilitates the transportation of blood, oxygen, and nutrients to various tissues and organs.
Understanding the anatomy and function of major blood vessels is essential for comprehending the circulatory system and diagnosing and treating cardiovascular conditions.
USMLE CVS 001 Mediastinum anatomy medical chest .pdfAHMED ASHOUR
The mediastinum is the central compartment of the thoracic cavity, located between the lungs.
It is a three-dimensional space that houses various structures within the chest.
The mediastinum extends from the sternum (front of the chest) to the vertebral column (back of the chest) and from the superior thoracic aperture (top of the chest) to the diaphragm (bottom of the chest).
Understanding the anatomy of the mediastinum is crucial for healthcare professionals to interpret diagnostic findings and manage conditions affecting this central compartment of the thoracic cavity.
USMLE CVS 004 Coronary circulation and venous drainage heart.pdfAHMED ASHOUR
The blood supply to the heart is crucial for its function as a muscular organ that pumps blood to the rest of the body.
The coronary circulation provides oxygen and nutrients to the heart muscle (myocardium).
Understanding the blood supply to the heart is crucial for diagnosing and treating cardiovascular conditions, and interventions such as coronary artery bypass grafting (CABG) may be performed to restore blood flow to the heart muscle in certain cases.
Join live classes, download study aids, sell your documents, join or host your own classes online, get tutoring, tutor students, take practices tests and more at Examville.com
Here is a detailed presentation on anatomy of heart
I sincerely agree that few of my slides are copied and most of them are prepared by myself
But that is how we help each other!!
Hope the presentation helps the one in need
And it's free to download for anyone
The whole purpose of uploading is.. So that anyone can use it ..
How do the healthcare profession engage and convert potential customers into patients when using social media?
HBT Media has extensive experience developing and executing successful marketing strategies and campaigns for clients across the healthcare industry
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
2. The aorta is the main trunk of a series of vessels which
convey the oxygenated blood to the tissues of the body
for their nutrition.
It commences at the upper part of the left ventricle,
where it is about 3 cm in diameter, and after ascending
for a short distance, arches backward and to the left side,
over the root of the left lung.
It then descends within the thorax on the left side of the
vertebral column, passes into the abdominal cavity
through the aortic hiatus in the diaphragm, and ends,
considerably diminished in size (about 1.75 cm. in
diameter), opposite the lower border of the fourth lumbar
vertebra, by dividing into the right and left common iliac
arteries.
Branches: The ascending aorta, the arch of the
aorta, and the descending aorta, which is again divided
into the thoracic and abdominal aorta.
THE AORTA
3.
4. THE AORTIC VALVE
The aortic valve, or aortic semilunar valve, has three leaflets or cusps.
It is located at the base of the aorta. It opens to allow blood to leave
the left ventricle as it contracts. When the ventricular muscles relax,
the valve closes to prevent blood from backing up into the ventricular
chamber.
5. ASCENDING AORTA (Aorta Ascendens)
The ascending aorta is about 5 cm. in length.
It commences at the upper part of the base of the left ventricle, on a level with the lower border
of the third costal cartilage behind the left half of the sternum; it passes obliquely upward,
forward, and to the right, in the direction of the heart’s axis, as high as the upper border of the
second right costal cartilage, describing a slight curve in its course, and being situated, about 6
cm. behind the posterior surface of the sternum.
At its origin it presents, opposite the segments of the aortic valve, three small dilatations called
the aortic sinuses.
At the union of the ascending aorta with the aortic arch the caliber of the vessel is increased, owing
to a bulging of its right wall. This dilatation is termed the bulb of the aorta, and on transverse
section presents a somewhat oval figure.
The ascending aorta is contained within the pericardium, and is enclosed in a tube of the serous
pericardium, common to it and the pulmonary artery
Branches: The only branches of the ascending aorta are the two coronary arteries (Right &
Left) which supply the heart; they arise near the commencement of the aorta immediately above the
attached margins of the semilunar valves.
6. ARCH OF AORTA (Arcus aorta/transverse aorta)
The arch of the aorta is the second major anatomical region of
the aorta; it curves above the heart between the ascending and
descending aorta. All of the blood delivered from the heart to the
systemic tissues of the body passes through the aorta, making it
the largest artery in the human body. As the aorta extends from
the heart, it begins as the ascending aorta before turning 180
degrees towards the body’s left side in the aortic arch. From the
arch the aorta passes posterior to the heart and descends
through the thorax and abdomen as the descending aorta.
Branches: Three major arteries branch off from the superior
arterial wall of the aortic arch to supply blood to the tissues of the
superior regions of the body: the brachiocephalic trunk, left
common carotid artery, and left subclavian artery.
The brachiocephalic trunk is the first artery to arise from the
aortic arch, carrying blood to the right arm and the right side of
the head and neck. Next to branch from the aorta is the left
common carotid artery that supplies blood to the left side of the
head and neck. Finally, the left subclavian artery arises from the
aortic arch and supplies blood to the left arm.
7. DESCENDING AORTA
Although the descending aorta is positioned to the
left of the body's midline, it gradually descends to
directly in front of the vertebral column at the left
of the 12th thoracic vertebra.
The portion of the descending aorta above the
diaphragm is called the thoracic aorta, and gives
off branches into the thoracic wall.
Branches of thoracic aorta: The Bronchial
arteries, Mediastinal arteries, Esophageal arteries,
Pericardial arteries, Superior phrenic arteries &
supply blood to the organs for which they were
named.
Below the diaphragm, the descending aorta
become the abdominal aorta and stems off into
branches that reach the abdominal wall and
various tissues and organs of the abdomen.
9. Epidemiology
Ruptured abdominal aortic aneurysms (AAAs) cause 12,000 deaths per year, 8,000 of these are infra-renal.
Women are much less frequently affected.
Ruptured abdominal aortic aneurysm (AAA) is one of the most fatal surgical emergencies, with an overall
mortality rate of 90%.
Rupture of a thoracic aneurysm has a greater than 97% fatality rate.
Risk factors
The presence of an aneurysm is a risk for rupture.
The larger the lesion, the more likely it is to bleed; aneurysms over 6 cm have a 25% annual risk of rupture.
Smoking and hypertension are additional risks.
A ruptured aneurysm should be considered whenever a man aged over 55 or a
woman aged over 70 presents with circulatory collapse.
10. PATHOPHYSIOLOGY
Aorta consists of 3 layers- Intima, Media & Adventitia.
Certain diseases causes weakening of the aortic walls , reduces its elasticity.
When blood is pumped through these weakened areas, it bulges out, which are
called aneurysms.
As the flow and thus the pressure through this area increases, it causes the
rupture of the aneurysm of the aortic wall.
11. Clinical Presentation
A ruptured aneurysm usually presents with pain.
Ruptured Thoracic aortic aneurysm (RTAA)
It will cause chest pain , Ripping sensation in chest, Severe back pain, between shoulder
blades
Haemoptysis (erodes to trachea), Hematemesis (erodes into esophagus) can occur.
Dizziness, Hypotension, Syncope
Difficulty in walking or speaking
If bleeding occurs into the mediastinum, it can cause cardiac tamponade and rapidly be fatal.
The patient will probably never reach hospital alive and the diagnosis is made post-mortem.
12. Ruptured Abdominal aortic aneurysm (RAAA)
Ruptured AAA presents with a classical triad of pain in the flank or back, hypotension and a
pulsatile abdominal mass; however, only about half have the full triad. Tachycardia
develops. Shock may occur.
The patient will complain of the pain and may feel cold, sweaty and faint on standing.
The following symptoms are listed with approximate frequency of presentation
• Abdominal pain (60%)
• Back pain (70%)
• Syncope (30%)
• Vomiting (20%)
16. Anterior intraperitoneal rupture
A tear in the anterior wall of the aneurysm results in sudden severe abdominal or back pain and collapse.
The resultant bleeding into the peritoneal cavity is so rapid that exsanguination and death usually occur before
the patient reaches the hospital.
Posterior retroperitoneal rupture
Classical clinical picture
Rupture into the retroperitoneal cavity is the most common site of ruptured AAA .
A tear in the posterolateral aneurysm wall leads to retroperitoneal bleeding which manifests clinically as back pain
with or without abdominal pain and hypotension.
This tear is often sealed for a few hours, which allows time for the transfer of the patient to the hospital,
diagnosis, and treatment.
On examination, a pulsatile epigastric mass is often palpable, particularly in a thin patient. But this mass may not
be palpable in obese or distended patients or in those with severe hypovolaemia.
17. Unusual presentations of ruptured abdominal aortic aneurysm
The temporary sealing of the tear in the aneurysm wall may rarely extend beyond a few hours. This results in a variety
of misleading symptoms and signs because of the extension of the retroperitoneal haematoma and its compressive
effects.
In ruptured AAA the duration of symptoms may be unusually long, and that an abdominal pulsatile mass may be
absent.
Transient lower limb paralysis
Right hypochondrial pain
Nephro ureterolithiasis
Groin pain
Testicular pain
Testicular ecchymosis (blue scrotum sign of Bryant)
Iliofemoral venous thrombosis
Inguinoscrotal mass mimicking a hernia
18. The three most frequent emergency presentations of ruptured AAA and their immediate management are:
•A patient known to have an AAA presents with a sudden onset of abdominal or back pain and
hypotension
•A patient presents with the classical triad of pain, hypotension, and a pulsatile mass.
In the two previous scenarios, a haemodynamically unstable patient should be immediately transferred to the
operating theatre for emergency open repair. Recently, endovascular aneurysm repair (EVAR) has been successfully
used to treat ruptured AAA.
In hospitals with capabilities for EVAR, a haemodynamically stable patient can undergo a preoperative computed
tomography (CT) scan, and if the anatomy of the aneurysm is suitable, the patient can undergo endovascular repair
for his/her ruptured aneurysm.
•A patient is suspected of having a ruptured AAA, regardless of the symptoms and signs, and is
haemodynamically stable.
This patient should undergo a CT scan to confirm the diagnosis and assess his/her suitability for EVAR.
Emergency presentations of ruptured AAA
19. Chronic contained rupture of AAA
Although most patients with ruptured AAA have an acute presentation, some patients may escape detection for
weeks or months after the aneurysm ruptures. This usually occurs when a retroperitoneal rupture leads to slow
progressive bleeding which forms a large haematoma that is contained by the resistance of the periaortic tissues.
Approximately 4% of ruptured AAA are contained ruptures. They are also known as "sealed" or "spontaneously
healed" aneurysms.
Most patients with a contained rupture are haemodynamically stable with no manifestations of acute blood
loss. But a contained rupture is a ruptured aneurysm in a stable patient that may progress to free rupture at any
time. Thus, urgent surgical treatment within 24 h, preferably after admission to an intensive care unit, is
necessary.
Most patients with a contained rupture present with chronic back pain that may radiate to the groin. Other
reported presentations includes lumbar vertebral erosion, lumbar spondylitis-like symptoms, left lower limb
weakness or neuropathy, crural neuropathy, left psoas muscle haematoma, and obstructive jaundice.
Rupture into the abdominal veins
Rarely, AAA ruptures into the inferior vena cava or the left renal vein. This results in an aortocaval fistula or an
aorta–left renal vein fistula, respectively.
20. Aortocaval fistula
A spontaneous aortocaval fistula most commonly occurs when an AAA erodes (ruptures) into the inferior
vena cava
Approximately 3–4% of patients with ruptured AAA have an aortocaval fistula.
In these patients, the manifestations of rupture usually dominate the clinical picture and significantly
diminish the chance of preoperative diagnosis.
Aortocaval fistulae are probably missed in 50% of patients and are discovered accidentally during elective
repair of AAA.
Trauma and surgery of the lumbar spine are other known causes of aortocaval fistulae.
The manifestations of an aortocaval fistula are variable because they depend on the size of the communication
between the aorta and the inferior vena cava.
Thus, temporary or permanent closure of this communication by an aortic mural thrombus or by a
compressing aneurysm will change the clinical picture.
21. The discovery of an aortocaval fistula during surgery is associated with major blood loss and the possibility of
pulmonary embolization with thrombus material from the aneurysm sac. Thus, unless the patient presents in
extremis due to the rupture, every effort should be made to detect the fistula preoperatively.
Abdominal CT scan is the definitive imaging test for the evaluation of AAA, and all patients suspected of
having an aortocaval fistula should undergo a contrast CT whenever possible.
Characteristic CT findings are loss of the fat plane between the aorta and inferior vena cava, vena caval
effacement, and direct inflow of contrast from the aorta to the inferior vena cava.
Clinically, a patient with an aortocaval fistula presents with a classical triad of abdominal or back pain, a
pulsatile abdominal mass, and a continuous bruit on abdominal auscultation.
This triad is reported in 50–90% of patients.
Patients with an aortocaval fistula may also present with manifestations of high output heart failure such as
dyspnoea, tachycardia, wide pulse pressure, cyanosis, and lower limb oedema.
Additional symptoms and signs include angina, palpitations hypotension, fever, oliguria,
haematuria, pulsatile peripheral veins, and diminished lower limb pulses.
22. Aorta–left renal vein fistula
It most commonly occurs when the wall of an infrarenal AAA erodes into the left renal vein.
The left renal vein normally crosses in front of the abdominal aorta on its way to the inferior vena cava. In 1–
2.4% of people, however, the vein crosses behind the aorta.
A retro aortic left renal vein is involved in more than 90% of cases of aorta–left renal vein fistula.
The "abdominal pain, haematuria, silent left kidney" syndrome described by Mansour et al summarises
the clinical features of aorta–left renal vein fistula.
Haematuria is the most important clinical feature in this condition, followed by pain which is usually felt in the
left flank and radiates to the groin, mimicking ureteric colic.
A pulsatile abdominal mass and a left sided continuous bruit are detected in approximately 60% and
70% of patients, respectively.
Renal dysfunction is usually seen in 85% of patients.
High output heart failure, similar to that seen in an aortocaval fistula, can also be seen in patients with an
aorta–left renal vein fistula. The degree of heart failure depends mostly on the size of the fistula.
Although extremely rare, an aorta–left renal vein fistula should be ruled out if a patient with an AAA develops
haematuria, left loin pain, or manifestations of renal dysfunction.
23. A contrast CT scan of the aorta can visualise the fistula, which should be looked for if a retro aortic left renal vein
is seen.
Preoperative diagnosis can avoid unnecessary blood loss when the aneurysm is opened during surgery. Intra
operatively, a palpable thrill over the aneurysm, or an absent left renal vein anterior to the aorta, should raise
suspicion of an aorta–left renal vein fistula.
An extremely rare cause of haematuria is an aortoureteric fistula. Here, the communication is usually between the
ureter and a previously inserted aortic graft, but it can also occur with an aortoiliac aneurysm.
The triad of unilateral hydronephrosis, intermittent haematuria, and previous aortic surgery should alert the
clinician to this life threatening but potentially curable disease.
24. Rupture into the bowel (aorto enteric fistula)
An aorto enteric fistula is an abnormal communication between the abdominal aorta and the bowel; it may be
primary or secondary.
A primary aorto enteric fistula connects an infra renal AAA to the bowel, most commonly the duodenum
(aortoduodenal fistula). This condition is often fatal but fortunately rare, with an estimated incidence at autopsy of
0.04–0.07%.
A secondary aorto enteric fistula is a late postoperative complication due to erosion of a prosthetic aortic
graft into the duodenum. This condition is more common, occurring in 0.5–2.3% of patients after aortic surgery.
The third and fourth parts of the duodenum are most commonly involved in an aorto enteric fistula because this
duodenal segment is closely applied to the anterior wall of the aorta, being fixed posteriorly by the ligament of
Treitz. However, communications with other parts of the gastrointestinal tract have also been reported.
Patients with a primary aortoduodenal fistula commonly present with upper gastrointestinal haemorrhage
(hematemesis, melena, haematochezia). Abdominal pain and a pulsatile abdominal mass may also be
present; however, patients rarely have all three findings.
Gastrointestinal haemorrhage was the most common presentation in patients with primary aortoduodenal fistula,
occurring in 96% of patients. Massive haemorrhage is uncommon initially; patients usually experience an episode
of small brisk bleeding which stops spontaneously. This "herald bleed" is characteristic of an aortoduodenal
fistula
25. Oesophagogastroduodenoscopy (OGD) is likely to be the first diagnostic test done in patients with upper
gastrointestinal haemorrhage, even if the cause of the bleeding is an aortoduodenal fistula.
OGD is useful to rule out the much more common causes of bleeding such as gastroduodenal ulcers and
oesophageal varices. If bleeding is due to an aortoduodenal fistula, OGD may not be precise in visualising the
fistula because of failure to pass the endoscope into the third or fourth parts of the duodenum.
Consequently, in patients with known or previously treated AAApresenting with unexplained upper
gastrointestinal haemorrhage, CT has emerged as the most important initial diagnostic test to rule out an
aortoduodenal fistula. Highly suggestive findings on CT include loss of the fat plane between the aorta and
duodenum and the presence of air in the retroperitoneal cavity.
Unless a primary gastrointestinal source of bleeding has been unequivocally identified in a bleeding patient
with AAA, an aortoduodenal fistula should always be ruled out.
Currently, the preoperative diagnosis of aortoduodenal fistulae is reached in only 50% of patients.
26. RUPTURED AAA IN CHILDREN
• Aortic aneurysms are extremely rare in children, and their aetiology is different from those in adults.
• In children, aortic wall infection, vasculitis, and connective tissue disorders are important causative
factors for AAA.
• Umbilical vein catheterisation is also a well recognised cause of childhood AAA, possibly
through infection.
• Most AAAs in children present as painless pulsatile masses; But a few alarming cases of rupture
have been reported.
• Ruptured AAA is not often suspected in children; But its fatal & should immediately rule out ruptured
AAA in children if it is suspected.
27. Physical Examination
A patient with a ruptured aneurysm at any level is likely to look pale and unwell and to be cold and sweaty.
The pulse will be rapid, weak and thready. Hypotension is common.
With a ruptured AAA there may well be a pulsatile mass in the vicinity of the bifurcation of the aorta. This is a few
centimetres above the umbilicus and a little to the left.
It may be tender and a bruit may be audible. Bleeding causes peritoneal irritation and it may appear as an acute
abdomen.
The following findings are listed with approximate frequency:
Palpable mass (90%).
Tenderness (80%).
Systolic blood pressure (BP) below 80 mm Hg (40%).
NB: presentation can be atypical, eg: intestinal obstruction from haematoma or an apparent irreducible inguinal
hernia.
Rare presentations are:
Severe hematemesis from an aorto -duodenal fistula.
A fistula into the inferior vena cava, producing lower limb oedema and high-output cardiac failure.
28. Differential diagnosis
The differential diagnosis for a ruptured TAA is that of chest pain, especially MI with cardiogenic shock but
also massive pulmonary embolism.
The differential diagnosis for ruptured AAA involves other causes of abdominal pain, including acute abdomen.
Investigations
If an aneurysm is ruptured, investigations need to be swift and pertinent.
Laboratory studies
CBC: NB: if there has not been time for haemodilution then haemoglobin will be normal. Anaemia is present in
less than half of patients. Around 80% have a white cell count of 10 x 109/L or more.
CMP
Group and rapid cross-match: whilst arranging surgery.
Baseline biochemistry of U&Es: should be performed.
29. Radiology
CXR: for a TAA the CXR may well show an enlarged base of aorta.
Plain abdominal X-ray: for an AAA this will show the lesion in about 75%, as it is often calcified.
Portable ultrasound: this examination may be helpful but there is not time for detailed assessment. If there is
strong suspicion of a ruptured aneurysm then immediate surgery may be the investigation of choice.
Other investigations: CT angiography will confirm the diagnosis. MRI and angiography are an alternative
but, practically, more time-consuming so probably only suitable for the stable patient.
ECG
ECG: is important In patients presenting with chest pain.
30. TREATMENT
Abdominal aortic aneurysms (AAAs) are typically repaired by an operative intervention.
The possible approaches are the traditional open laparotomy, newer minimally invasive methodologies, or by
the placement of endovascular stents.
INDICATIONS:
Open repair:
Diameter of the aneurysm greater than 2 inches
Abdominal Pain
Abdominal Pulsation
Endovascular repair:
Severe Heart diseases
Age risks
Other underlying medical conditions
31. PRE-OPERATIVE MEASURES
•Type and cross match blood
•IV line (fluids, antibiotics, anesthesia)
•Administer prophylactic antibiotics (cefazolin, 1 g intravenous piggyback)
•Insert a Foley catheter
•Monitor central venous pressure or establish Swan-Ganz catheterization (if
indicated)
•Prepare the skin from the nipples to the mid thigh
•Administer general anesthesia (open), general/regional anesthesia (endovascular)
•Insert a nasogastric tube
32. Open repair of an abdominal aortic aneurysm involves
an incision of the abdomen to directly visualize the aortic
aneurysm. The procedure is performed in an operating
room under general anaesthesia.
The surgeon will make an incision in the abdomen either
lengthwise from below the breastbone to just below the
navel or across the abdomen and down the centre.
Once the abdomen is opened, the aneurysm will be
repaired by the use of a long cylinder-like tube called a
graft. Grafts are made of various materials, such as
Dacron (textile polyester synthetic graft) or
polytetrafluoroethylene (PTFE, a non textile synthetic
graft). The graft is sutured to the aorta connecting one
end of the aorta at the site of the aneurysm to the other
end of the aorta.
4-6hrs duration
5-10 days hospital stay
Open repair
33.
34. Endo Vascular Aneurysm Repair (EVAR)
EVAR is a minimally-invasive (without a large abdominal incision)
procedure performed to repair an abdominal aortic aneurysm. EVAR
may be performed in an operating room, radiology department, or a
catheterization laboratory. Surgeon may use general anesthesia or
regional anesthesia (epidural or spinal anesthesia). The surgeon will
make a small incision in each groin to visualize the femoral arteries in
each leg. With the use of special endovascular instruments, along with
X-ray images for guidance, a stent-graft will be inserted through the
femoral artery and advanced up into the aorta to the site of the
aneurysm. A stent-graft is a long cylinder-like tube made of a thin
metal framework (stent), while the graft portion is made of various
materials such as Dacron or polytetrafluoroethylene (PTFE) and may
cover the stent. The stent helps to hold the graft in place. The stent-
graft is inserted into the aorta in a collapsed position and placed at the
aneurysm site. Once in place, the stent-graft will be expanded (in a
spring-like fashion), attaching to the wall of the aorta to support the
wall of the aorta. The aneurysm will eventually shrink down onto the
stent-graft.
2-3hrs duration
2-3 days hospital stay
35.
36. Postoperative Details
Fluid shifts are common following aortic surgery. Fluid requirements may be high in the first 12 hours,
depending on the amount of blood loss and fluid resuscitation in the operating room.
Monitor the patient in the surgical intensive care unit for hemodynamic stability, bleeding, urine output, and
peripheral pulses.
A postoperative electrocardiogram and chest radiograph are needed.
Prophylactic antibiotics (eg, cefazolin at 1 g) are administered for 24 hours.
The patient is seen in 1-2 weeks for suture or skin staple removal, then yearly thereafter.
37. Complications of the procedure
Open repair
• Myocardial infarction (heart attack)
• Irregular heart rhythms (arrhythmias)
• Bleeding during or after surgery
• Injury to the bowel (intestines)
• Limb ischemia (loss of blood flow to legs/ feet)
• Embolus (clot) to other parts of the body
• Infection of the graft
• Lung problems
• Kidney damage
• Spinal cord injury
EVAR
• Damage to surrounding blood vessels, organs, or
other structures by instruments
• Kidney damage
• Limb ischemia (loss of blood flow to leg/feet) from
clots
• Groin wound infection
• Groin hematoma (large blood-filled bruise)
• Bleeding
• Endo leak (continual leaking of blood out of the
graft and into the aneurysm sac with potential
rupture)
• Spinal cord injury
38. Prognosis
No more than 1 in 3 patients with a ruptured aortic aneurysm will reach hospital alive, and 20% of those who do, fail
to reach theatre.
Delay in diagnosis is a major risk factor. Elective repair of AAA has a mortality of around 5% compared with 60-80%
for emergency repair.
The following factors are associated with a mortality rate in excess of 80%:
Age over 80.
Presentation in shock with free intraperitoneal rupture.
Failure of BP to rise, despite attempts at resuscitation.
Haematocrit below 25% on admission.
Preoperative cardiac arrest.