Acute Aortic Dissection Presenting as Rectal Tenesmus

Abstract

BACKGROUND Acute aortic dissection (AAD) is a life-threatening medical emergency that requires a high index of clinical suspicion to be diagnosed promptly. The variability in the clinical presentation of AAD has historically made it difficult to identify in the acute setting. There remains significant inter-physician variability in the use of imaging. The median time to diagnosis in the Emergency Department is over 4 h and AAD has a mortality rate of 68% when diagnosis is delayed by over 48 h after onset of symptoms. CASE REPORT We discuss a case of a 69-year-old woman presenting with gastrointestinal symptoms in the Emergency Department who ultimately was found to have AAD. The patient had delayed presentation by 12 h due to misattribution of her rectal tenesmus to irritable bowel syndrome. However, after a thorough history and physical exam, the Emergency Medicine physician appropriately risk-stratified the patient and correctly diagnosed her with a Stanford Type A aortic dissection using a computed tomography study of the chest, abdomen, and pelvis with intravenous contrast. CONCLUSIONS AAD is an uncommon disease often requiring emergency intervention. We summarize the research and scoring systems and discuss the physical exam findings, comorbidities, imaging modalities, and risk stratification tools. Although imperfect, the Aortic Dissection Detection Risk Score with the addition of a D-dimer test is currently the best-validated tool and should be an important part of clinical decision making prior to performing computed tomography imaging.

Figure 1.

Computed tomography with IV contrast demonstrating a Stanford Type A aortic dissection. Arrows indicate intimal flap.

Figure 2.

Computed tomography with IV contrast demonstrating extension of the aortic dissection to the level of the renal system. Arrow indicates intimal flap.