What are the symptoms of abdominal aortic dissection?

Symptoms of Abdominal Aortic Dissection

Abdominal aortic dissection typically presents with sudden-onset, severe abdominal pain that is often described as sharp, ripping, tearing, or knife-like in quality, with the abruptness of onset being the most specific characteristic. 1

Primary Symptoms

• Pain characteristics:

  • Abdominal pain occurs in approximately 25% of patients with aortic dissection 1
  • Pain may be non-specific in up to 40% of cases with abdominal involvement 1
  • Pain may migrate as the dissection progresses along the aorta 2
  • Unlike myocardial infarction pain, dissection pain is typically maximal at onset rather than gradually increasing 2

• Associated symptoms:

  • Back pain (commonly present in Type B dissections that extend into the abdominal aorta) 1
  • Syncope (occurs in approximately 15% of patients with Type A dissection and less than 5% with Type B) 1
  • Hypotension or shock (may result from aortic rupture or major blood loss) 1

End-Organ Ischemia Signs

• Mesenteric ischemia:

  • Abdominal pain may be the only presenting symptom 1
  • Clinical manifestation is frequently insidious 1
  • Diagnosis is often delayed, leading to poor outcomes 1

• Renal involvement:

  • Elevated serum creatinine
  • Refractory hypertension
  • Oliguria or anuria 2

• Lower extremity symptoms:

  • Painful or numb lower extremities due to end-organ ischemia 1
  • Pulse deficits (present in up to 20% of patients) 2
  • Limb ischemia 2

Atypical Presentations

• Painless dissection:

  • Occurs in approximately 6.4% of patients 1
  • More common in older patients
  • More likely to present with syncope, stroke, or congestive heart failure 1
  • More common in patients on steroids or with Marfan syndrome 1

• Misdiagnosis pitfalls:

  • May mimic acute coronary syndrome, pulmonary embolism, or even cholecystitis 3
  • Clinicians fail to initially consider aortic dissection in up to 35% of cases 3

Risk Factors to Consider

• Most common risk factors:
  • Hypertension (present in 65-75% of cases, often poorly controlled) 1
  • Male gender 1
  • Advanced age (mean age 63 years) 1
  • Pre-existing aortic diseases 1
  • Genetic connective tissue disorders (Marfan, Loeys-Dietz, Ehlers-Danlos syndromes) 2, 4
  • Bicuspid aortic valve 4

Diagnostic Considerations

• ADD risk score (Aortic Dissection Detection) considers:

  • High-risk predisposing conditions
  • Pain features (abrupt onset, severe, ripping/tearing)
  • Physical examination findings (pulse deficit, blood pressure differential, focal neurologic deficit) 1

• Warning signs:

  • Patients with abdominal pain as the primary symptom are less likely to be suspected of having aortic dissection (only 8% compared to 86% for those with chest and back pain) 1
  • Abdominal aortic dissections share similar presentation with thoracic dissections, including acute shearing pain and systolic hypertension 5

Remember that abdominal aortic dissection can be fatal if not promptly diagnosed and treated, with a mortality rate of 1-2% per hour in untreated patients 4. The key to diagnosis is maintaining a high index of suspicion, especially in patients with risk factors who present with sudden-onset abdominal or back pain.