Right flank pain: inferior vena c”>American Journal of Emergency Medicine 34 (2016) 2050.e1-2050.e3

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American Journal of Emergency Medicine

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Case Report

Deadly right flank pain: inferior vena cava Spontaneous rupture?

Abstract

Inferior vena cava (VCI) spontaneous rupture is a rare clinical case. It is generally diagnosed via laparotomy in the absence of any personal history. We hereby present a case that applied to the emergency department (ED) with flank pain, who was discharged in the first appli- cation with renal colic diagnosis and who was afterward diagnosed with aorta dissection combined with VCI spontaneous rupture during the urgent operation. Our objective was to increase awareness by emphasizing the fact that VCI spontaneous rupture might be the cause of massive intra-abdominal hemorrhage without being related with trauma.

A 31-year-old male patient was admitted to the ED with right flank pain and epigastric abdominal pain that started an hour ago. The pain was stabbing and colicky in nature, and he had nonspecific urinary symptoms. He treated himself unsuccessfully with non-steroidal analgesics. He had undergone an operation for spontaneous Duodenal ulcer perforation 3 years prior, and an operation for spontaneous cecum perforation 2 years prior. On clinical examination, although the patient was fully conscious, he looked pale. He had right flank sensitivity and abdomen was normal. His pulse rate was 88 per minute, and his blood pressure was 130/70 mmHg. There was no significance in the chest radiography and the standing direct abdominal radiography. Urine analyses showed 3.5 red blood cells in every field. He was diag- nosed as renal colic and treated with fluids and intravenous non- steroidal analgesics. After the symptoms were relieved, he was discharged. Twelve hours after being discharged, he was readmitted to the emergency department since his pain gradually worsened. He was examined again and palpation revealed tenderness on both inferior sides of his abdomen with Generalized rigidity and right flank tender- ness. Rectal examination was nonspecific. laboratory investigations documented normochromic, normocytic anemia with a hemoglobin of

10.9 g/dL. The clotting profile was normal. Biochemical analyses of the blood showed no specific problems. Urine analyses showed minimal blood (4.5 red blood cells). Electrocardiogram was normal. Chest x-ray showed no abnormalities. USG showed no intra-abdominal free fluid. Fluid hydration was started at the ED but following the onset of hypo- tension and confusion during the follow-up, abdominal tomography was applied with fluid support in the accompaniment of Emergency doctors as a result of which intraabdominal and retroperitoneal free fluid was observed. It was determined that the abdominal aorta was dis- sected and ruptured from the iliac artery level (Figs. 1 and 2).

? The abstract of this study was presented as e-poster at the 10th National and 1st Inter- continental Congress of Emergency Medicine, Antalya, Turkey, 15-18 May 2014.

A laparotomy was performed by the attending cardiothoracic sur- geon. After the initial incision, the patient went into cardiac arrest. Peri- operative CPR was performed for 90 minutes but the patient was nonresponsive and declared dead. Surgery showed free blood in the peritoneal cavity. The VCI was ruptured 1 cm around the inferior renal vein junction. The abdominal aorta had no aneurysm but was dissected and also ruptured just before iliac bifurcation.

Post-mortem examination was carried out the same day which showed no further bleeding.

VCI rupture occurs mostly due to blunt or penetrating trauma and has a mortality rate of about 57% to 95% [1]. The spontaneous rupture of VCI is rarely observed without any prior trauma [2], and there are only 3 reported cases in the literature [3,4,5]. There was no predisposing factor in the history of one of the reported cases, whereas the second one had a right nephrectomy operation due to tuberculosis and the third had a history of enoxaparin use [3,4,5]. In our case, there was an abdominal operation due to 2 previous spontaneous duodenum and colon rupture. Although this anamnesis led us to consider a possible un- diagnosed connective tissue disease, no other Predisposing factors were observed.

Patients with VCI rupture might arrive at the ED in a state of hemor- rhagic shock which is a severe clinical state. It has been stated in litera- ture that the period of time between the onset of complaints and the development of hemorrhagic shock varies between 1 hour and 10 days. This time period was recorded as 6 hours in the case that we re- ported. abdominal distension, abdominal pain and back aches, and peri- toneal irritation findings can be observed in such cases [5,6]. Our patient had applied with complaints of pain in the side flank thus leading us to consider renal colic.

VCI was ruptured from 1 to 2 cm superior of iliac vein bifurcation in the 3 reported cases and whereas in 2 of the cases the placement was on the anterior surface, it was on the posterolateral surface for 1 of the pa- tients. In our case, VCI spontaneous rupture was at the infrarenal level and was fixed via primary suturing. It was observed following the diag- nostic exploration after the patient was accepted as exitus that the aorta was dissected and ruptured at the bifurcation level of the iliac vein. Al- though aorta-caval fistula had been previously reported in literature, the hemorrhage focuses were independent of each other, which set the case apart from the others.

Death in other cases occurred due to postoperative organ failure, whereas it occurred during the operation in our case. We believe that the reason for the early death of our case is due to the combination of VCI spontaneous rupture with aorta dissection. The fact that the patient was diagnosed with renal colic during the first application delayed the early diagnosis of these diseases which have high mortality rates even when considered separately.

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Fig. 1. contrast extravasation due to the abdominal aorta dissection rupture.

The annual incidence of aorta dissection is estimated to be around 5 to 20 in a million [7]. However, aorta dissection diagnoses are increasing with advancements in radiological imaging technologies. It is generally observed in patients above the age of 40 years [8,9].

There are many factors that might cause acute aorta dissection devel- opment such as hypertension, connective tissue diseases, atherosclerosis, pregnancy, iatrogenic and traumatic factors, and infective diseases [10].

The typical clinic of aorta dissection is defined as severe chest ache in the form of a rupture or fracture. Based on the retention of aorta branches, sensory and motor changes in the lower extremities, abdom- inal pain, blood pressure differences between the 2 arms, and sudden blood pressure changes can be observed [11]. However, diagnosis is de- layed and mortality rates increase when patients with aorta dissection apply to hospitals with nonspecific symptoms, which are different from the Classic symptoms [12]. That is why; clinical suspicion plays an important role in diagnosis. The fact that the clinical symptoms were not classic in our patient and that he was not diagnosed with con- nective tissue disease despite the previous operations resulted in the di- agnosis of renal colic in the emergency.

Both spontaneous VCI rupture and aorta dissection hemorrhage are very difficult diagnoses on a young patient, and they are very mortal cases. Patients can apply to emergency clinics with symptoms similar to those of renal colic thus making it difficult to place the correct diagnosis. Therefore, emergency clinic doctors should question the history of their pa- tients in detail and should not refrain from imaging for mortal diagnoses. They should always keep in mind the diagnosis of spontaneous VCI rupture.

Conflict of Interest: None declared.

Zeynep Karakaya, MD^? Erden Erol Unluer, MD Aysen Ersan, MD

Department of Emergency Medicine, Katip Celebi University Ataturk Training and Research Hospital Izmir, Turkey

^?Corresponding author. Katip Celebi University, Ataturk Training and Research Hospital, Department of emergency medicine Izmir, Turkey Tel.: +90 232 2444444 2452; fax: +90 232 2434848

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2016.02.055

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   Fig. 2. A, The intra-abdominal hemorrhage. B, The Retroperitoneal hemorrhage.

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