Background
Aortic dissection is a life-threatening vascular emergency that typically presents with chest or back pain, but it can manifest atypically with abdominal symptoms. This case is noteworthy for its unusual presentation—isolated abdominal pain as the initial manifestation of a Stanford type B aortic dissection involving the superior mesenteric artery (SMA). The case highlights a rare but critical diagnostic consideration when evaluating patients with signs of acute bowel ischemia.
Case Presentation
A 49-year-old male with a history of hypertension presented to the emergency department with sudden-onset, severe, diffuse abdominal pain. He denied any chest or back pain. On arrival, vital signs were notable for blood pressure of 172/96 mmHg, heart rate of 118 bpm, respiratory rate of 22, temperature of 37.1°C, and oxygen saturation of 97% on room air. He appeared acutely ill—diaphoretic and in visible distress. Physical examination revealed diffuse abdominal tenderness without guarding or rebound. Laboratory studies demonstrated a white blood cell count of 18.4 x10⁹/L, lactate of 4.6 mmol/L, creatinine of 1.8 mg/dL (baseline unknown), and a mildly elevated D-dimer. Liver enzymes and lipase were within normal limits. A CT abdomen and pelvis with IV contrast showed signs concerning for bowel ischemia. CT angiography of the chest, abdomen, and pelvis subsequently revealed a Stanford type B aortic dissection extending to the SMA, with evidence of compromised mesenteric perfusion. Vascular and cardiothoracic surgery were consulted emergently. The patient underwent endovascular repair of the aortic dissection, followed by exploratory laparotomy, which confirmed necrotic bowel requiring resection.
Conclusion
This case illustrates the diagnostic challenge of atypical aortic dissection presentations, particularly when chest or back pain is absent. Isolated abdominal pain and laboratory markers of ischemia should prompt consideration of a vascular cause, especially in patients with known hypertension. Early imaging, including CT angiography, is critical for timely diagnosis and intervention. Clinicians should maintain a broad differential diagnosis for acute abdominal pain to avoid delays in identifying catastrophic vascular
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Acute Abdominal Pain as the Initial Presentation of Aortic Dissection with Superior Mesenteric Artery Involvement by Blake Martin