What is the diagnosis and treatment for a patient presenting with tearing abdominal pain radiating to the back, suspected to have an abdominal aortic aneurysm (AAA)?

Ruptured or Impending Rupture of Abdominal Aortic Aneurysm

A patient presenting with tearing abdominal pain radiating to the back has a ruptured or impending rupture of an abdominal aortic aneurysm (AAA) until proven otherwise and requires immediate ICU admission with urgent surgical repair within 24-48 hours. 1, 2

Immediate Clinical Recognition

This presentation represents a life-threatening emergency:

• Tearing or ripping abdominal pain radiating to the back is the cardinal symptom of AAA rupture or impending rupture, occurring in 65-90% of cases 2, 3
• The pain may also radiate to the flank or groin 2
• Any patient with known AAA presenting with acute abdominal, back, or flank pain should be presumed to have impending rupture 1
• Even without a known AAA history, this pain pattern in patients over 65 years (especially men with hypertension or smoking history) mandates immediate evaluation 4, 2

The pain quality is highly specific—described as abrupt onset, severe, sharp, tearing, or ripping—and this abruptness of onset is the most characteristic feature 4

Critical Diagnostic Pathway

Hemodynamic Status Determines Next Steps

For hemodynamically stable patients:

• Obtain CT angiography immediately to confirm rupture and assess anatomy for repair planning 1
• CTA has 91.4% sensitivity and 93.6% specificity for diagnosing rupture 2, 5
• Look for periaortic stranding, contrast extravasation (active bleeding), intramural hematoma, or perivascular hematoma sealed by retroperitoneal structures 1, 2

For hemodynamically unstable patients:

• Bedside ultrasound can detect AAA presence with 99% sensitivity and 98% specificity, though it cannot reliably confirm rupture 1
• Transfer immediately to operating room without delaying for CT if shock is present 1

Key Imaging Findings

Three critical patterns exist 1, 2:

• Contained rupture: Hemodynamically stable, sealed hemorrhage by retroperitoneal structures, perivascular hematoma visible
• Impending rupture: Acute pain with preserved wall integrity but intramural hematoma on non-contrast CT phase
• Free rupture: Contrast extravasation, massive hematoma, hemorrhagic shock

Immediate Management Protocol

Hemodynamic Stabilization (Before Repair)

Establish invasive monitoring and ICU transfer immediately 1:

• Place arterial line for continuous blood pressure monitoring 1
• Target systolic BP <120 mmHg (or lowest BP maintaining end-organ perfusion) 1
• Target heart rate 60-80 bpm to reduce aortic wall stress 1
• Initiate IV beta-blockers as first-line therapy unless contraindicated 1
• Provide aggressive pain control, which is essential for hemodynamic management 1

Definitive Surgical Repair

Urgent repair within 24-48 hours is mandatory to prevent progression to free rupture 1:

• Endovascular aneurysm repair (EVAR) is preferred over open repair when anatomically suitable, reducing perioperative mortality from 29-33% to 19-23% 1
• Local anesthesia is preferred over general anesthesia for EVAR to further reduce perioperative mortality 1
• Open surgical repair remains necessary when anatomy is unsuitable for EVAR 1
• Symptomatic aneurysms require urgent treatment regardless of diameter—even aneurysms <5.5 cm can rupture 4, 1

Critical Pitfalls to Avoid

Atypical Presentations Can Delay Diagnosis

• Up to 6.4% of patients present without pain, particularly older patients, those on steroids, or patients with Marfan syndrome 4
• These patients may present with syncope (27.8% sensitivity), stroke, or heart failure instead 4, 5
• Classic triad of hypotension (30.9% sensitivity), pulsatile mass (47.1% sensitivity), and pain is present in only a minority 5
• The absence of classic symptoms does not rule out rupture 5

Gender-Specific Considerations

• Women experience rupture at smaller diameters than men and have poorer prognosis due to atypical presentation and delayed diagnosis 4, 1, 2
• Saccular AAAs can rupture at smaller sizes than fusiform aneurysms 1

Post-Repair Complications

• Up to 20% of ruptured AAA patients develop abdominal compartment syndrome, which nearly doubles mortality 1
• Consider open abdomen management if abdominal compartment syndrome risk is high 1
• Risk factors for rapid deterioration include massive resuscitation requirements, blood loss >5 liters, and use of aortic balloon occlusion 1

Underlying Pathophysiology

Nearly all patients with AAA rupture have hypertension, often poorly controlled 4, 2. The rupture occurs when wall stress exceeds wall strength, with chronic pulsatile trauma potentially causing vertebral body erosion in thoracoabdominal aneurysms 4. The mean diameter at rupture is approximately 7 cm, though 25% of acute presentations occur at <5.5 cm 4, 6.