Three words — abdominal aortic aneurysm — spoken to a patient conjures up one word: fear. Please address AAA in your daily column for the sake and benefit of the multitude of those aware and unaware of potential ramifications of this nefarious disease. I have read that 1,500 Americans lose their lives to this condition every year.

Our doctor has failed to satisfactorily address my questions about my husband’s condition during the past four years. The only medication he takes is Lovostatin daily for slightly elevated cholesterol. What causes AAA? What causes fat in the liver?

We look forward with great anticipation reading your learned knowledge of the disease, treatment options and advice.

DEAR READER: I’m not sure I can begin to measure up to your perceived inflated interpretation of my knowledge, but perhaps I can shed some light on your unanswered questions.

An AAA occurs when a portion of the aorta, the large blood vessel that supplies oxygen-rich blood to the abdomen, pelvis and legs becomes abnormally large or bulges outward. The aorta runs from the heart through the chest and abdomen. An aneurysm can develop anywhere along the aorta. When they occur in the upper portion of the aorta, they are known as thoracic aortic aneurysms. Similarly, when they occur in the lower portion of the aorta, they are called abdominal aortic aneurysms. While an unusual occurrence, when one develops between the upper and lower portion, they are known as thoracoabdominal aneurysms. Most small and slow-growing aneurysms will not rupture, and there will be few, if any, symptoms. The larger the aneurysm, the more likely it will rupture. Anyone can develop an aneurysm, but they are most commonly seen in males over the age of 60 who have at least one risk factor, such as high blood pressure, obesity, high cholesterol levels, a history of smoking, atherosclerosis, or specific genetic factors such as Marfan Syndrome, Ehlers-Danlos Syndrome, heart-valve problems, and injury.

Symptoms of a rupturing AAA can include nausea, vomiting, low blood pressure, loss of consciousness, abdominal or back pain that presents rather suddenly but persistently, clammy skin and a rapid heart rate. Examination by a physician might reveal a rigid abdomen, a pulsating sensation near the navel or a mass. While a physician might be able to palpate a mass, he or she may choose to do nothing for a non-rupturing one but monitor its size to determine whether it enlarges. If it is extremely slow growing, the aneurysm may not require any intervention other than monitoring; however, should blood from the aneurysm leak into the abdominal cavity or if it grows rapidly, surgical repair will likely be necessary unless the risks outweigh the benefits.

If a physician determines surgery can be avoided, at least temporarily, he or she may prescribe a beta blocker to slow the rate of growth of the aneurysm. In your husband’s case, he was prescribed medication to lower his cholesterol level. High levels are associated with plaque, fat deposits (from dietary choices or genetics) and a buildup of atherosclerosis and pressure on arteries. If surgery is agreed upon, there are two possibilities for repair. The first and most common is grafting the abnormal vessel with manmade material, such as Dacron. This procedure requires that a large incision be made into the abdomen. The second, known as endovascular stent grafting, doesn’t require the large incision of open repair. It has fewer risks than grafting. It is accomplished by inserting a needle in the area of the groin and advancing a catheter to the site of the aneurysm. Dye is then injected to help guide the placement of a stent graft device. Once in place, the device prevents blood flow through the aneurysm, greatly reducing the risk of rupture. Because long-term effects of this latter procedure haven’t been fully investigated, stent grafts are generally performed in patients thought to be at too high a risk for conventional repair. The prognosis is quite good for either procedure as long as the aneurysm is repaired prior to rupture. Without complications, patients are generally discharged home in four to seven days following the procedure and can resume normal activity within a month.

Prevention of an aneurysm can be accomplished through exercise, eating a healthful, low-cholesterol diet, avoiding stress and treating hypertension.

Most people diagnosed with an AAA live symptom-free, healthy lives. Guidelines for surgery are dependent on medical history, the size of an aneurysm and the rate at which it enlarges. The decision is best left to your husband’s physician.

To give you related information, I am sending you a copy of my Health Report “An Informed Approach to Surgery.” Other readers who would like a copy should send a self-addressed, stamped No. 10 envelope and a $2 check or money order payable to Newsletter and forwarded to PO Box 167, Wickliffe, OH 44092-0167. Be sure to mention the title or print out an order form from my website www.AskDrGottMD.com.

My question to you is, what do I do now?

DEAR READER:
Abdominal aortic aneurysms (AAA) are potentially fatal areas of bulging or ballooning of the large blood vessel that supplies the abdomen, pelvis and legs. They can occur in anyone but are most common in males over 60 with one or more risk factors.

Those factors include emphysema, smoking, high blood pressure, obesity, high cholesterol, being male, and certain genetic factors. There is no known cause.

In most cases, the aneurysm is found during routine screening tests or imaging studies for other conditions. Most aneurysms do not cause symptoms. They usually develop slowly over time but occasionally expand rapidly leading to rupture, dissection (bleeding from the inner wall into the outer wall of the vessel) or other symptoms. All aneurysms carry risks but small ones generally go unnoticed. Large aneurysms are more serious and are more likely to rupture spontaneously and cause symptoms.

Symptoms are usually the result of rupture or dissection and include nausea, vomiting, back or abdominal pain, anxiety, clammy skin, an abdominal mass, abdominal rigidity, rapid heart rate upon standing, a pulsating sensation in the abdomen, and shock. Rupture is a medical emergency and immediate attention is necessary.

Treatment is available. Small, non-symptomatic aneurysms should be monitored on a yearly basis to check for expansion. If the aneurysm causes symptoms, rapidly expands, or is larger than 5.5 centimeters, surgery is often done to prevent complications such as leaks or rupture.

There are currently two types of surgery available. The first is a traditional version which involves making a large incision. The damaged vessel is then replaced with a synthetic material. The second is called endovascular stent grafting which uses several smaller incisions in the groin to access the vessels. The grafting material is then snaked up the artery and put into place in the abnormal area. This type of surgery may have a faster healing time but is not recommended for every sufferer.

If surgery is successfully performed before rupture, the outcome is generally favorable. However, if rupture occurs, less than 40% of patients survive.

I urge you to follow your surgeon’s advice. If you smoke, are overweight or have other risk factors, take steps to reduce or eliminate them. If you are still concerned, request a referral for another opinion.

To give you related information, I am sending you copies of my Health Reports “An Informed Approach to Surgery” and “Blood — Donations and Disorders”. Other readers who would like copies should send a self-addressed, stamped number 10 envelope and $2 per report to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title(s).

My husband is now 91 years old and a productive senior citizen who attends luncheon clubs, lodge meetings and is able to enjoy his family. We have been married 68 years and hope to have many more wonderful years ahead.

We know miracles happen and perhaps the disgruntled “professional consumer advocate” will admit he was wrong. Our family has proof.

DEAR READER:
I thought this issue had been put behind me but then I received your letter. I felt it was important to print it because it shows what competent and caring physicians can do.

Age doesn’t always have to be a limiting factor in deciding appropriate courses of medical treatment as your husband’s case clearly shows. I hope you both continue to lead productive, fulfilling lives together for many years to come. Thanks for writing.

In April 2005 I had an abdominal aortic aneurysm which burst while I was on the operating table. Against the odds I lived.

In July 2005 I developed two hernias which were treated non-invasively. In April 2006, I developed three hernias which were again treated non-invasively.

In May of 2006 I had surgery on my left carotid artery because it was 95% blocked. I was fine until March 2008 when I had to have surgery for another hernia. I have enclosed the hospital papers with this letter for your review.

Aug 2008 I returned to the same hospital because of more hernias. The doctor said they could not operate and that I would have to be seen by a specialist at a nearby medical university hospital or the Mayo Clinic. He said they couldn’t do the repair because any further operation might cause me to lose part of my stomach and/or large intestine. I have been wearing an abdominal binder but the bulges are very prominent and painful, especially when I cough which was often since I have COPD.

DEAR READER:
Thank you for sending some back up material as it was helpful in coming up with my answer.

Based on the report, all of your hernia problems have come from your abdominal aneurysm repair. The surgical incision has weakened in several areas allowing the hernias to form. During the first surgical repair, mesh was put in place to prevent further weakening of the area. During the second surgical repair, a new hernia occurred just on the edge of the old mesh and that the old mesh has grown into the flesh. You also had several severe adhesions (areas where two organs fuse together inappropriately). The adhesions where removed, as was the old mesh. A new, larger piece of mesh was put in place and the hernia repaired. At the same time, your umbilicus (belly button) was removed because it had adhered to the mesh.

All of this means that your while your first surgery successfully fixed the hernia, it eventually led to several potentially serious conditions caused by the healing process. Adhesions are essentially a buildup of scar tissue and in your case, this occurred between your stomach, small and large intestine and the surgical mesh. Your body healed too well which led to the problem.

Based on the findings of the second surgery and your current situation, it seems to me that you will continue to have issues with hernias. I am unsure of the cause of this, however, can understand the physician’s stance. Based on your last surgery, the hospital and surgeons are expecting more of the same. Even if your adhesions and hernias are less severe than the previous ones, damage has been done.

Removal of part of the stomach and intestine is major and can lead to complications. I agree with his recommendation to see super specialists at a teaching hospital or the Mayo Clinic. The physicians and surgeons here have access to the newest procedures and protocols. Perhaps they will be able to fix your hernias and prevent them from returning.

I urge you to make an appointment at one of the facilities for a consultation. Be sure to bring your medical records for review as they may play a crucial role in determining your next course of action.

To give you related information, I am sending you a copy of my Health Report “An Informed Approach to Surgery”. Other readers who would like a copy should send a self-addressed, stamped envelope number 10 and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

His stomach protrudes slightly but also has a smaller “bump” beyond that. It’s noticeable through t-shirts or when he lies flat and is located exactly where the internet information says an aortic aneurysm would be. I cannot find anything that says if one can be visually detected, though. This spot looks like a grapefruit is hidden in his stomach.

He is “medically dense” and doesn’t even know that it’s there. Looking straight at it in a mirror, it can’t be seen. I don’t want to raise a red flag if there is nothing to worry about.

DEAR READER:
To the best of my knowledge, an abdominal aortic aneurysm (AAA) is not visible through the skin because the vessel is located deep within the abdominal cavity.

Your male partner most likely has a hernia. This can be easily diagnosed by his personal physician and an ultrasound examination. Depending on the location and severity of the hernia, he may need surgery to repair it to ensure the loop of bowel that has become displaced doesn’t become necrotic (dead) and cause serious problems. Testing is especially important if he is having bowel problems or abdominal pain.

The technician should be able to do an AAA screening at the same time as the hernia screening if that is something that is still a concern. As I have said before, men over the age of 50 should be checked for abdominal aneurysms. At age 71, your partner is, in my opinion, overdue for the test.

If you are truly concerned about him, I urge you to speak to him. I am sure he would be more than willing to see his doctor to put you at ease. Don’t push and nag. Simply voice your concerns and wishes. Show him my answer to your question.

DEAR READER:
These flyers are extremely useful in directing you to testing offered in your area. The services are offered at a fraction of the cost charged by your local hospital or health care center. The flyer you sent me publicizes screening for carotid artery stenosis (a common cause of stroke), abdominal aortic aneurysm (a potentially fatal thinning and ballooning of the major artery feeding the lower body), osteoporosis (a determination of bone strength in men and women), and peripheral vascular disease (arterial blockages in the legs).

I encourage you to partake in the program offered unless you have had recent, similar testing performed. All procedures offered are non-invasive, completely painless screenings using Doppler ultrasound technology.

A board certified physician who is fully insured and licensed to practice medicine will review and confirm all results. Should you have any abnormal readings, I recommend you take the reports provided to your own primary care physician for interpretation and possible follow-up.

To give you related on two of the conditions mentioned, I am sending you copies of my Health Reports “Stroke” and “Osteoporosis”. Other readers who would like copies should send a self-addressed, stamped number 10 envelope and $2 (per report) for each report to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title(s).

You are the “Dear Abby” of medical journalism and you should be ashamed of yourself.

I am, by profession, a consumer advocate so you had better take my words seriously.

For the purpose of this letter I will remain anonymous; however, you will know my name if this malpractice continues.

DEAR READER:
I’m sorry that you disagree with my column which I write to keep people informed about medical issues. Judging from the 2500 letters I receive each week, my readers are glad to have this information. I think this makes me a successful consumer advocate, unlike you. In all the years I have written this column, I have received only a handful of letters such as yours. I believe this is inevitable — but sad in a way because such people are missing the point. I recommend that you have some anger management therapy and perhaps a few typing, grammar and spelling lessons as well. (It took quite a while to correct your letter to make it passable for a syndicated column.) Doing a spell check and re-reading your letter for errors before sending it is always a good idea for those who wish to be taken seriously, so forgive me that I‘m not “shaking in my boots“ at your threats.

Now, to the article in question. If you had read the letter from this gentleman, you would have known that his vascular surgeon RECOMMENDED the surgery. He also had a friend (who happened to be a physician) recommend surgery if the aneurysm grew. So you see, I was simply a third party physician who recommended the surgery as well. I hope your next letter, which I am certain will be a response to this, will be more thought out. Thanks for writing. I needed a chuckle today!