Sometimes pain in the lower back isn’t really back pain. Sometimes pain in the lower back is related to more serious conditions such as urinary tract infections, kidney stones, tumors, or, as this story reveals, an abdominal aortic aneurysm.

Recognition of the patient’s signs and symptoms is critical if the correct – and potentially lifesaving – diagnosis is to be made. This story will help the reader question his or her symptoms should they experience rapidly worsening back pain that appears from seemingly out of the blue.

He caught my eye the minute he strolled into the emergency room, just before midnight. He had wrapped both hands around his lower back and kept straightening up, as if to work out a kink. The resident examined him first.

“Seventy-one-year-old man with back pain,” he reported. “Began six hours ago, and it’s getting worse. Funny thing is, he didn’t lift anything heavy, or fall. Should I give him something for the pain?”

“Can you find where it hurts?” I asked.

“I checked along his back. Nothing.”

“Pulses?” I continued.

He frowned. “I forgot to check.”

“Maybe,” I said, “it isn’t his back.”

I went over to say hi. The patient had the weathered mien of a smoker.

“Hello, doctor,” he said in a gravelly voice. “I need something for this pain.”

I pressed up and down his back: no sore muscles or tender vertebrae. His belly hurt a little in the left lower quadrant. Above his navel, I felt carefully for a pulsing, painful fullness but found none. The pulses in his groin seemed a little uneven—: the right stronger than the left—: but I couldn’t be sure. Most intriguing was the appearance of his legs. A lacy pattern of blue seemed to play over them, a mottling that suggested his blood wasn’t circulating well.

“I’m not sure what’s causing your pain,” I confessed. “Until I am, I can’t give you anything for the pain. It would only mask things.”

“It hurts. Hurts like a bear, doctor.”

“Soon as I can. I promise.”

The resident and I stepped away.

“What are you thinking?” he asked.

“Triple-A: abdominal aortic aneurysm.”

“But shouldn’t we be able to feel it?”

“Not always. He needs a diagnosis,” I said. “Preferably in the next five minutes.”

It’s easy to forget that the aorta arches off the heart, diving down through the diaphragm and running along the left side of the spinal column. At the level of the navel, it forks into two big arteries, the iliacs, to feed the lower body. Buried beneath the abdominal wall and the intestines, shielded from the rear by ribs and back muscles, the abdominal aorta lies at our very pith. Thick and resilient, it swells with every squeeze of the heart’s left ventricle, then smoothly recoils to keep the pressure wave moving along. This elasticity is its Achilles’ heel. Age, combined more often than not with the insults of cigarette smoking and atherosclerosis, can weaken the aortic wall in the upper abdomen until it balloons like a worn inner tube.
(Read The Rest of the Story)

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