Imaging Case of the Week 6

A 70 year old female patient presents at 2am with vague abdominal pain that woke her up from her sleep. She has vomited once. Her past history includes hypertension and previous laparotomy for appendicectomy. She clearly looks pale and uncomfortable. Her heart rate is 100 and her blood pressure is 100/60 mmHg. You are worried as you have read somewhere that any pain that wakes a patient up at night is sinister. You want to rule out a bowel obstruction and request an abdominal xray. The radiographer has been unable to perform an erect chest and abdominal xray as patient is dizzy when she attempts to sit up. Here is the supine abdominal film. What does it show?

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The xray does not show what you were expecting (dilated bowel loops). There is a left hip prosthesis. Is there any finding in the xray that should worry you?

The xray shows a calcified dilated AAA with an xray diameter of nearly 7 cm. In a patient with abdominal pain and signs of shock, this should alert you to the possibility of a leaking AAA which is a vascular surgical emergency. A quick bedside ultrasound should confirm the finding.