Acute Type B aortic dissection (A. Type B AD) is a vascular emergency that may present atypically, delaying diagnosis. A 49-year-old man having poorly controlled hypertension presented with acute epigastric pain radiating to the left chest, without classic tearing epigastric pain radiating to left chest and back. Initial ECG was normal, only with mild troponin elevation on labs. CT aortography revealed a simple A. Type B AD confined to the descending thoracic aorta, without rupture or malperfusion. The patient was managed uilizing aggressive medical therapy, including IV β-blockade and strict BP control, and promptly referred to a tertiary vascular center. This case highlights the diagnostic challenge of atypical pain and the importance of early CT imaging and guideline-directed medical management to improve outcomes.
Acute AD is a life-threatening emergency caused by sudden intimal tearing with blood entering the medial layer to form a false lumen; despite advances in imaging and critical care, mortality and morbidity remain high, rising hourly without treatment, making rapid diagnosis and immediate management the key determinants of survival [1].
It typically comes with sudden severe “tearing” chest or even back pain with hypertension, arrhythmia, or neurological symptoms, but many patients—especially with Type B dissections—show atypical pain in the abdomen, epigastrium, neck, or jaw, often mimicking cardiac, hepatobiliary, or gastrointestinal disease and delaying diagnosis [2,3].
Diagnosis is challenging as ECG discoveries are often normal or non-specific and labs may show mild troponin or inflammatory marker elevation, misleading clinicians toward ACS; acute Pancreatitis and Gastritis thus, high clinical suspicion is essential, particularly in patients having risk factors like uncontrolled hypertension, male gender, and middle age [4,5].
CT aortography is the preferred emergency diagnostic tool due to its speed, accuracy, and ability to define dissection extent and complications, enabling early classification into Type A or Type B, which is critical for management, as Type A requires urgent surgery while uncomplicated Type B is managed medically; this case highlights the diagnostic difficulty of Type B dissection presenting as epigastric pain and underscores the importance of early CT imaging and guideline-directed care to improve outcomes [5,6]..
A 49-year-old man showed up with sudden, severe epigastric pain radiating straight to the left chest with intensity sufficient to force him into a tripoding posture, lasting 15–30 minutes, worsened by movement, without associated symptoms, prompting consideration of both cardiac and intra-abdominal causes due to its atypical location and intensity.
The patient was given a 12-lead ECG upon arrival. Figure 1 shows that the ECG showed normal sinus rhythm with possible left atrial enlargement and no acute ischemia ST-segment or T-wave alterations. There was no sign of bundle branch block or left ventricular hypertrophy.
Figure 1. ECG graph.
Laboratory evaluation revealed a mildly elevated troponin I level of 130 ng/L. No D-dimer, serum amylase, or chest radiograph was obtained prior to definitive imaging, as the patient’s persistent severe pain and uncontrolled hypertension prompted urgent advanced imaging.
An urgent contrast-enhanced CT aortogram was conducted due to concerning nature of pain and clinical examination and the suspicion of a vascular emergency. Imaging showed there was an A. Type B AD only in the descending thoracic aorta. There existed no involvement of the ascending aorta or aortic arch. There existed no pleural effusion, pericardial effusion, or mediastinal hematoma, and the lung fields looked clear.
Figure 2 shows axial contrast-enhanced CT image of the thorax demonstrates a well-defined intimal flap within the descending thoracic aorta (indicated by the red arrow), separating the vessel into a true lumen (A) and a false lumen (B). The true lumen appears relatively smaller and more opacified, while the false lumen is larger, consistent with an acute Type B aortic dissection. The ascending aorta is not involved on this slice, supporting the classification as Type B. No mediastinal hematoma, pleural effusion, or pericardial effusion is evident, indicating an uncomplicated dissection at the time of imaging.
Figure 2. Axial CT Aortogram Demonstrating Type B Aortic Dissection.
Emergency Management and Outcome
The patient was promptly relocated to the resuscitation area and treated per known aortic dissection protocols. Intravenous labetalol was given as three 20-mg boluses with airway, breathing, and circulation simultaneously assessed and maintained followed by a continuous infusion, with the objective of maintaining a systolic BP under 120 mmHg. Continuous cardiac and hemodynamic monitoring was initiated, and the patient was swiftly escalated to the emergency medicine consultant and vascular surgery teams. After stabilization, the patient was moved to a tertiary vascular surgery center in Leeds for definitive specialist care.
Figure 3. Aortic dissection involving the descending aorta.
This paper describes an atypical and simple Type B AD with epigastric pain radiating to left chest and back as symptom, no classic chest or even back pain, no autonomic signs or focal neurological abnormalities. The patient was stable, the ECG normal with minor changes, no obvious consequences like organ malperfusion or aortic rupture which all added to the diagnostic confusion. The case, which was in contrast to dissection cases, did not present rapidly progressive life-threatening complications; on the contrary it was rather a diagnostic problem than a therapeutic emergency thus highlighting the risk of delayed detection.
The most significant distinction is in the symptoms and the early complication profile. Classic dissections make themselves known through very loud symptoms and quick death, while atypical Type B dissections may be clinically unnoticed even if there is a very serious disease underneath. The new and important understanding from this comparison is that lack of classic features does not mean low risk, and good history taking and examination at early CT imaging is of great importance in detecting such hidden dissections. This case supports expanding clinical suspicion beyond classic presentations to include atypical pain patterns as indicators of significant aortic disease.
This uncomplicated A. Type B AD presenting as isolated epigastric pain highlights clinically important insights that support and extend existing evidence. Atypical dissection symptoms, such as abdominal or epigastric pain rather than classic chest or back pain, are increasingly recognized and pose significant diagnostic challenges in emergency settings. Epidemiological and educational studies show a substantial proportion of dissections present atypically, making reliance on chest-focused algorithms inadequate and underscoring the need for broader clinical suspicion, particularly in patients with risk factors such as uncontrolled hypertension and sudden severe abdominal pain [7]. In this case, prompt CT imaging was pursued due to severe pain and hypertension, aligning with current guidelines recommending early imaging when clinical suspicion is high. Most emergency departments (EDs) use CT aortography as the first diagnostic because it is quick, sensitive, and may show how far the problem has spread and what complications it has caused (true vs. false lumen, branch vessel involvement, mediastinal hematoma). Early CT avoided delays and misdiagnosis from non-specific tests despite non-informative ECG and ACS, Pancreatitis and Gastritis, aligning with ACC/AHA and STS/AATS recommendations for immediate imaging and expert involvement in suspected acute aortic syndromes [8]. Uncomplicated Type B disease is best managed with ICU transfer, rapid BP control using IV β-blockade, IV morphine and urgent surgical consultation, with guidelines favoring medical therapy; although preemptive TEVAR may benefit select high-risk patients, risks and timing remain uncertain, supporting strict medical management with individualized planning [9]. The case shows that reproducible pain does not exclude dissection, mild troponin rise cannot distinguish myocardial injury from dissection, CT should not be delayed, and early β-blocker is preferred over isolated vasodilators, reinforcing prior reports and guidelines [10]. It also underscores the need for trials, registries, and ED pathways enabling rapid imaging in atypical TBAD, as early suspicion and prompt CT may be life-saving and reduce morbidity [11].
Download PDF
Download PDF
Download PDF
Download PDF
+91 9063922599
+91 9063922599
editor@healthcare-bulletin.co.uk
Download XML
