Infrarenal aortic aneurysm: an incidental radiological finding Marina Yiasemidou, MBBS, MSc

Objectives To demonstrate the importance of extensive revision of imaging testing To demonstrate the importance of considering alternative diagnosis

Imaging options for loin pain Intravenous Urogram (IVU) CT Scan Ultrasound

History 71 year old man Worsening colicky left sided flank pain radiating to his groin for 2 days One year history of intermittent left sided pain, similar in nature but of reduced severity No other significant past medical history

On Examination A-Patent B- Good bilateral air entry RR:12 C- HS: S1-S2 - Heart rate: 92 bpm, - Right arm blood pressure 134/87 mmHg D- GCS 15/15 PEARL E-tender left loin with guarding abdomen was otherwise soft no palpable masses no renal bruits normal bowel sounds femoral pulses: (+) bilaterally, equal warm, pink extremities

Investigastions Urine dipstick: microscopic haematuria and proteinuria. Abdominal X-ray: Normal FBC, U+Es, LFTs: Unremarkable Intravenous urogram (IVU) (to exclude ureteric calculi) no renal tract calcifications normal, unobstructed pelvicalyceal systems larger distance between the lumbar vertebrae and the left ureter in comparison to the right side

Intravenous Urogram

?Alternative diagnosis Abdominal computerised tomography

patient was referred to vascular team CT findings 9.6 x 9.3 cm infrarenal aortic aneurysm extending up to the bifurcation of the aorta No ureteric calculi were identified patient was referred to vascular team

CT Abdomen

Discussion History and examination findings consistent with ureteric colic Physical examination did not reveal any signs indicative of abdominal aortic aneurysm. Incidental finding of the abnormally unequal distance between the lumbar vertebrae and ureters, identified on IVU imaging, was the only sign of the final diagnosis.

Ureteric calculi diagnosis IVU Lower radiation Lower cost Gives information about functional status of kidneys degree of obstruction Spiral CT Underlying pathology If eventually needed its diagnostic value will be diminished by attempting IVU first (residual dye, load on kidneys)

High threshold of identifying an IVU as normal Conclusion High threshold of identifying an IVU as normal

Thank you