An 83-year-old man presented to the emergency department with coffee ground emesis, hypotension and tachycardia. He was found to have a well-defined pulsatile mass in the abdomen. Emergency endoscopy showed oesophageal varices, which were treated endoscopically.

Axial computed tomography (CT) scan (without contrast) of the abdomen was done to rule out abdominal aortic aneurysm (AAA) leak or fistulous communication with gastrointestinal tract. The CT scan revealed a very large AAA (fig 1) measuring 10.1 cm in horizontal diameter, which extended from the vertebra to the abdominal wall and was creating a bulge on the abdominal wall (arrows). The aortic wall was partly calcified but no leak was noted from the aorta throughout the retroperitoneal space.

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Figure 1 Non-contrast axial computed tomography scan of the abdomen showing 10.1 cm (horizonal diameter) abdominal aortic aneurysm (arrows) with partially calcified intact wall.

No leak is noted.

Following a detailed discussion with the patient and family members about the risks versus benefit of surgery, he was treated conservatively. The family decided for hospice and comfort care only and the patient died of continued gastrointestinal blood loss.

Incidental finding of AAA has been described in abdominal ultrasonography series,1 as well as during emergency presentations.2 Surgical options are limited in patients with poor medical conditions because vascular surgery falls under the highest risk non-cardiac surgery in terms of perioperative cardiac risks.