Type B aortic dissection atypically presenting as chronic abdominal pain

Aortic dissection type B is a cardiovascular emergency of the descending thoracic aorta, which can lead to visceral malperfusion, a potentially life-threatening complication. Mortality rates of acute visceral ischaemia have been reported to be as high as 25% to 62% [1–3]. As well as pharmacotherapy, other therapeutic options are available to restore intestinal blood flow, including various endovascular and surgical procedures [2].
We report a case of a 53-year-old woman who presented with constant central abdominal pain that radiated to the back. Abdominal symptoms occurred approx. 30 days prior to hospital admission and were followed by recurring vomiting and diarrhoea. There were no relieving factors and no other associated symptoms – in particular, there was no chest pain, urinary symptoms, or neurological deficits. Her medical history included well controlled arterial hypertension. She had no smoking history and was an occasional drinker. Physical examination did not elicit any findings apart from mild abdominal distension, epigastric tenderness, and decreased intestinal sounds. Her chest was clear with normal heart sounds, and blood pressure was 140/85 mm Hg. The blood pressure in the right arm was unfortunately not documented. All other observation readings were within normal range. The results of liver and kidney function tests, electrolytes, amylase, lipase, and cardiac enzymes were within normal range. Inflammatory markers were raised, with a C-reactive protein level of 105.3 mg/l (normal value, < 10.0 mg/l) and a leukocyte count of 14,590 per cubic millimetre (reference range: 4000 to 10,000 mm–3). Except for a moderately prolonged prothrombin time of 18.20 s (reference range: 10.4 to 12.5 s), the results of blood and coagulation tests were unremarkable. A 12-lead electrocardiogram indicated no abnormalities. On presentation her abdominal ultrasound and chest radiography were normal. She was sent for an emergent esophagogastroduodenoscopy. The findings are shown in Figure 1. Small bowel infarction was suspected, and she was transferred for an emergent computed tomography (CT), which revealed thickening of the duodenal wall and Stanford type B and DeBakey type IIIb acute aortic dissection (AAD), starting from the left subclavian artery, running along the aortic arch and descending aorta, and reaching distal to the right common iliac artery (Figure 2). The patient was referred for endovascular stent grafting.
Intestinal...


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