A Vague Pain with a Serious Secret

Author: Khaled R. Mohammed / Editor: Stephen Sheridan / Codes: SLO3, VC1, VC2 / Published: 20/04/2026

A 91-year-old man arrives in the Emergency Department (ED) complaining of a 2-3 week history of dull right hip and lower back pain.

He describes the pain as a deep ache without clear triggers. It radiates slightly towards the back but not the leg. Analgesia from his GP brings only partial relief, and he has attended twice previously with a presumed diagnosis of sciatica.

He denies nausea, vomiting, urinary symptoms, bowel changes, chest pain, shortness of breath, fever, or neurological deficits. His background includes lumbar spinal stenosis, knees osteoarthritis, hypertension, mitral valve prolapse and treated skin carcinomas. He takes antihypertensives and paracetamol.

On examination, he is alert, comfortable, and haemodynamically stable. His abdomen is soft with no palpable mass. Peripheral pulses are present. His right hip shows discomfort on movement but no erythema, swelling, or neurological deficit. Scattered ecchymoses are noted on both legs.

Given his age, persistent atypical symptoms, and increasing discomfort, you perform a bedside aortic ultrasound. The scan appears to show a large aneurysmal dilation near the aortic bifurcation, raising concern for vascular pathology. This prompts urgent CT angiography showing massive 9.4 cm right internal iliac artery aneurysm (Fig. 1 & 2).