What are the next steps for a patient with pulsating sensations in the right upper abdomen and suprapubic area, accompanied by pain?

Immediate Diagnostic Evaluation for Pulsatile Abdominal Pain

This patient requires urgent imaging with CT angiography (CTA) of the abdomen and pelvis to evaluate for abdominal aortic aneurysm (AAA) with possible rupture or dissection, as pulsatile abdominal pain in multiple locations is a critical red flag for vascular catastrophe. 1

Critical Initial Assessment

The combination of pulsatile sensations in the right upper abdomen progressing to painful pulsatile suprapubic sensations raises immediate concern for:

• Abdominal aortic aneurysm (AAA) - The pulsatile quality in two distinct abdominal locations suggests a large AAA that may be expanding or dissecting 1
• Aortic dissection - Progressive pulsatile pain migrating from upper to lower abdomen can indicate dissection propagating distally 1
• Ruptured AAA - The addition of pain to previously painless pulsations is highly concerning for impending or contained rupture 1

Physical Examination Priorities

Immediately assess for:

• Palpable pulsatile abdominal mass - A pulsatile mass on palpation strongly suggests AAA and raises concern for nonischemic vascular emergency 1
• Hemodynamic instability - Tachycardia, hypotension, or signs of shock indicate possible rupture requiring immediate surgical consultation 1
• Unequal peripheral pulses or blood pressure differential ≥15 mmHg between arms - Suggests aortic dissection 1
• Peritoneal signs - Rigidity, guarding, or rebound tenderness indicates possible rupture with intraperitoneal hemorrhage 1

Immediate Diagnostic Imaging

CTA of the abdomen and pelvis with arterial and venous phases must be performed immediately despite any renal insufficiency, as the consequences of delayed or missed diagnosis are far more detrimental than contrast exposure 1:

• CTA provides 93-96% sensitivity and 97-100% specificity for detecting vascular pathology 1
• Arterial phase demonstrates thrombus, aneurysm size, and abnormal vessel enhancement 1
• Venous phase identifies venous thrombosis and organ infarction 1
• Multi-planar reconstructions assess vessel origins and extent of pathology 1

Do not delay imaging for laboratory results - The clinical presentation warrants immediate vascular imaging 1

Alternative Diagnoses to Consider

While vascular catastrophe is the primary concern, other causes of pulsatile abdominal pain include:

• Mesenteric ischemia - Severe abdominal pain out of proportion to physical findings, though typically not described as pulsatile 1
• Bladder pathology with pelvic fracture - Suprapubic pain with inability to void, though pulsatile quality would be unusual 1
• Intra-abdominal infection with vascular involvement - Pulsatile pain could represent mycotic aneurysm 1

Critical Management Steps

If hemodynamically unstable:

• Activate massive transfusion protocol immediately 1
• Obtain emergent vascular surgery consultation without waiting for imaging 1
• Initiate fluid resuscitation with crystalloid and blood products 1
• Administer broad-spectrum antibiotics 1
• Proceed directly to operating room if rupture suspected 1

If hemodynamically stable:

• Obtain CTA immediately 1
• Keep patient NPO pending imaging results 1
• Establish large-bore IV access 1
• Type and crossmatch for potential surgery 1
• Consult vascular surgery urgently regardless of imaging findings given clinical presentation 1

Common Pitfalls to Avoid

• Do not assume pulsations are normal aortic pulsations - The progression from painless to painful pulsations and involvement of multiple abdominal regions is pathologic 1
• Do not delay imaging for "stable" vital signs - Patients with contained AAA rupture may maintain blood pressure temporarily before decompensation 1
• Do not perform ultrasound as the primary imaging modality - While ultrasound can detect AAA, it cannot adequately assess for rupture, dissection, or mesenteric ischemia 1
• Do not withhold contrast due to renal concerns - The mortality risk of missed vascular pathology far exceeds the risk of contrast-induced nephropathy 1

Laboratory Studies

While imaging should not be delayed, obtain:

• Complete blood count - Assess for anemia from occult bleeding 1
• Lactate level - Elevated lactate suggests tissue ischemia from vascular compromise 1
• Type and crossmatch - Prepare for potential massive transfusion 1
• Coagulation studies - Baseline before potential surgery 1