Man with hypertension and abdominal pain

Abstract

A 61-year-old with history of hypertension and atrial flutter on rivaroxaban presented to the emergency department from a cardiology clinic for uncontrolled hypertension. The patient reported intermittent, nonexertional, left-sided chest, and epigastric pressure. On examination, the patient had elevated blood pressure: left arm 240/131 and right arm 217/109. Vital signs were otherwise normal and physical examination was unremarkable. The patient's electrocardiogram showed no acute ischemic changes. Point-of-care ultrasound (Video 1 and Figure 1) and computed tomography angiography (CTA) (Figure 2) of the patient's aorta were obtained.

Spontaneous isolated celiac artery dissection (SICAD) is a rare visceral arterial dissection, the second leading type after superior mesenteric artery dissection. Symptoms can range from an asymptomatic incidental finding to severe epigastric, back, or flank pain in middle-aged adults.^{1, 2} The most prevalent risk factors include male sex, smoking, and hypertension.^{3, 4} CTA is the primary modality used to diagnose SICAD worldwide. Findings include an intimal flap, which is pathognomonic, or a mural thrombus in the celiac lumen. Complications include organ ischemia, aneurysm formation, and rupture.⁵ First-line treatment for SICAD is conservative management including strict blood pressure control, antithrombotic therapy, and surveillance. Surgical and endovascular intervention are reserved for patients who have failed conservative treatment.⁶

Our patient was admitted to the cardiac intensive care unit on a labetalol drip to treat hypertensive emergency. Vascular surgery was consulted and recommended addition of a daily aspirin and atorvastatin to his home medications and smoking cessation. The patient was discharged home in stable condition on hospital day 2.