A53-06 Atypical Aortic Dissection Presenting as Colitis and Fulminant Hepatic Failure

Abstract Introduction Aortic dissection is a rare but often fatal emergency with mortality rising 1-2% per hour after onset, making early diagnosis critical. The mean age at presentation is 63 years, and only about 7% of cases occur in patients under 40. The hallmark presentation is acute, severe chest or back pain, often accompanied by neurologic symptoms or pulse deficits. Computed Tomography Angiography (CTA) remains the diagnostic gold standard with 94-100% sensitivity. We present a fatal case of missed aortic dissection in a young male with atypical presentation and unknown risk factors. Case Description A 35-year-old obese male presented to the emergency department with acute abdominal pain, nausea, vomiting and bloody diarrhea after eating rice. Initial evaluation revealed leukocytosis (28 × 109/L) and mild transaminitis (AST 97 U/L, ALT 93 U/L). CT abdomen showed no acute pathology. He was treated for presumed sepsis secondary to infectious colitis but rapidly deteriorated, developing fulminant hepatic failure (AST/ALT 2,500 U/L), hyperammonemia ( 600 µmol/L), lactic acidosis (10 mmol/L), anuric renal failure, and respiratory distress requiring intubation. CTA abdomen revealed ileus without aneurysm or dissection but noted dilation at the left atrium-descending aorta junction (5.6 cm). Echocardiography showed normal ventricular function, mild aortic regurgitation, and dilation of the aortic root (5.1 cm) and ascending aorta (5.9 cm). He was transferred for liver transplant evaluation but deemed an unsuitable candidate due to refractory shock and neurological decline. He was transitioned to comfort care and subsequently passed. Autopsy revealed an extensive aortic dissection from the root to the common iliac arteries without aneurysm. Ischemic necrosis of the liver, bowel, mesentery, and kidneys confirmed malperfusion syndrome. Postmortem review uncovered a family history of fatal aortic rupture. Discussion Fulminant hepatic failure with colitis is an atypical presentation of aortic dissection, particularly in a young patient without typical risk factors such as hypertension, connective tissue disorders, or bicuspid aortic valve. Studies show younger patients tend to have higher rates of obesity and more extensive dissections, leading to greater visceral and lower limb malperfusion. Malperfusion syndrome results from partial or complete obstruction of branch vessels and can involve any major vascular territory, leading to diverse and often misleading clinical manifestations that may complicate diagnosis, as in this patient. Multi-organ failure should prompt clinicians to consider aortic dissection, even in the absence of hallmark symptoms or known risk factors, as early detection is crucial in reducing morbidity and mortality. This abstract is funded by: None