EpistemisVisible epigastric pulsation
Specialty: Cardiovascular.
Why it occurs
- Large diameter abdominal aortic aneurysm
- Severe aortic insufficiency (systemic hyperdynamic transmission)
- Extreme constitutional thinness (physiological transmission of normal aortic pulsation)
- Retroperitoneal tumor or pancreatic mass that transmits the heartbeat of the aorta
- Severe tricuspid regurgitation with hepatic pulsation transmitted to the epigastrium
- Hypertrophic and dilated right ventricle with low left parasternal beat (Dressler sign)
Initial workup
Emergency point-of-care abdominal ultrasound (POCUS) to measure the transverse and anteroposterior diameter of the abdominal aorta (a diameter >3 cm defines aneurysm, >5.5 cm indicates high risk of rupture); Computed tomography (CT) of the abdomen and pelvis with intravenous contrast (Angio-CT) to precisely define the anatomy of the aneurysm, presence of mural thrombus, signs of contained rupture or retroperitoneal hematoma; Transthoracic Doppler echocardiogram if right ventricular hypertrophy or severe tricuspid regurgitation is suspected.
red flags
Presence of a prominent, pulsating and expansive epigastric beat on deep abdominal palpation, associated with dull and continuous pain in the abdomen, flank or lumbar fossa of recent onset, sudden arterial hypotension, extreme mucocutaneous pallor, diaphoresis, syncope, or palpable abdominal mass that does not move laterally. These symptoms are characteristic of a symptomatic abdominal aortic aneurysm with imminent risk of rupture or already ruptured, constituting an extremely serious surgical emergency.
Standard management
- Esmolol — short-acting intravenous beta-blocker, indicated in symptomatic aortic aneurysm without rupture or in the dissection phase to reduce systolic blood pressure and parietal shear force; continuous infusion of 50 to 200 mcg/kg/min, adjusting according to MAP
- Ramipril — ACEI for the chronic and strict control of high blood pressure if the aneurysm is managed conservatively; 2.5 to 10 mg per day orally
- Atorvastatin — statin indicated to reduce the progression and stabilize the atheromatous plaque associated with the aneurysmal wall; 40 mg once daily orally
- Furosemide (diuretic if associated with central congestion due to right ventricular hypertrophy; 20 mg orally per day).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Cardiovascular
- Listed causes
- 6
- Treatment options
- 4