Abdominal pain (cardiovascular causes)
Inferior MI, aortic catastrophe, mesenteric embolism and congestive hepatopathy — all visible from the subcostal window.
Echo approach, step by step
Abdominal pain can be cardiovascular: inferior ischaemia, aortic dissection or aneurysm, mesenteric embolism, and congestive hepatomegaly. Pericarditis can also cause epigastric pain. The subcostal window sees the heart, IVC, hepatic veins and abdominal aorta in one sweep [138,174].
- Subcostal heartEffusion, RV size, LV function.
- Regional wall motionInferior and inferolateral walls [138].
- Abdominal aortaDiameter (aneurysm ≥30 mm), flap [174].
- Aortic rootFlap, AR [9].
- Embolic sourceLA and LV thrombus, vegetations, AF [136,140,182].
- CongestionIVC, hepatic veins, TR (tender hepatomegaly) [4].
- Inferior wall motion
- Abdominal aorta diameter and flap
- Thoracic aorta
- Embolic source
- IVC and hepatic veins
- Pericardium
Causes & echo clues
| Cause | Echo clue | Confirm |
|---|---|---|
| Inferior MI | Inferior RWMA; RV infarction | ECG, troponin [138] |
| Aortic dissection | Flap; malperfusion | CT angiography [9] |
| Ruptured AAA | Aneurysm ≥30 mm with free fluid | CT; surgery [174] |
| Mesenteric embolism | AF, LA or LV thrombus, vegetation | CT angiography [140,182] |
| Congestive hepatopathy | Plethoric IVC, severe TR, RV failure | LFTs [4] |
| Pericarditis | Effusion | ECG, CRP [125] |
Clinical pathway to the diagnosis
- ECG in all older patients with epigastric pain[138].
- Lactate, lipase, LFTs, troponin.
- Bedside ultrasoundHeart, aorta, free fluid.
- CT angiographyfor suspected mesenteric ischaemia, dissection or AAA [9,174].
Clinical pearls & pitfalls
PitfallMesenteric ischaemia presents with severe pain and a soft abdomen. AF or a recent MI with LV thrombus is the clue [140,182].
- Endocarditis can present with splenic or renal infarction and abdominal pain [136].
Red flags
- Pain out of proportion to examination with AF → mesenteric embolism [182]
- Pulsatile mass, back pain, hypotension → ruptured AAA [174]
- Epigastric pain with diaphoresis → inferior MI [138]
- Tearing pain radiating to the back → dissection [9]