Ruptured Aortic Aneurism

Clinical History

This 72 year old man presented with a story of intermittent vomiting over a period of 6 weeks. There was no associated pain. Examination revealed an obviously sick old man, with a blood pressure of 110/90 and a pulse rate of 96. The abdomen was distended, but there was no tenderness. The percussion note was resonant. In the ward his condition did not improve and the patient began to complain of pain in the back and to show increasing restlessness with hiccoughing. Following intravenous therapy he improved, but 6 days after admission he became cyanosed and dyspnoeic. Clinical examination at this stage revealed left loin tenderness and abdominal rigidity. The patient's condition deteriorated rapidly and he died.

Pathology

The specimen is an opened abdominal aorta viewed from behind and mounted in continuity with the renal arteries and kidneys. The intima of the aorta is markedly thickened due to extensive atheroma with focal calcification and patchy intimal ulceration. About 2 cm. above the bifurcation of the aorta there is a saccular aneurism 4.5 cm in diameter, filled with a mass of antemortem clot. The aortic wall bulges outwards on the left at this site. This aneurism has ruptured and bled into the retro-peritoneal fat around the left kidney, forming an ovoid peri-renal mass of clot and fat 20 cm. in longest diameter. The sectioned kidney shows some capsular thickening, mild cortical narrowing and an increase in peri-pelvic fat. There is marked granularity of the capsular surface of the right kidney, consistent with benign nephrosclerosis, i.e. the renal changes secondary to systemic hypertension. This is an example of rupture of a saccular atheromatous aneurism of the abdominal aorta.