Calcium Rim Sign in Plain Abdominal Radiograph: An Underrated Alert for Unstable Abdominal Aortic Aneurysm


Abdominal aortic aneurysm
Abdominal radiograph
Calcium rim sign

How to Cite

Ohn MH, Ng JR, Pey Luen N, Ohn KM. Calcium Rim Sign in Plain Abdominal Radiograph: An Underrated Alert for Unstable Abdominal Aortic Aneurysm. Surg Insights [Internet]. 2022 Sep. 9 [cited 2024 Jul. 19];. Available from:


Abdominal pain is a common presentation in the emergency department, and constipation is one of the commonest causes in elderly patients. We report a patient with a ruptured abdominal aortic aneurysm (AAA) who presented with features mimicking acute bowel obstruction. The abdominal radiograph, which showed a calcium rim sign, raised the suspicion of AAA. It was confirmed with contrast-enhanced computed tomography, which showed a large ruptured AAA. The patient was transferred immediately to a vascular center for urgent endovascular repair of AAA and made a complete recovery. This case highlighted the usefulness of plain abdominal radiography in diagnosing abdominal pain, which should not be taken for granted as it can aid in raising concerns of AAA. This case sends an important message, particularly to junior doctors, that symptoms of abdominal pain, vomiting, and total constipation can mask the possibility of AAA. Immediate treatment of a ruptured aortic aneurysm requires a high index of clinical suspicion.


Altobelli E, Rapacchietta L, Profeta VF et al. Risk Factors for Abdominal Aortic Aneurysm in Population-Based Studies:A Systematic Review and Meta-Analysis. International Journal of Environmental Research and Public Health. 2018;15(12):2805.

Bath MF, Sidloff D, Saratzis A et al. Impact of abdominal aortic aneurysm screening on quality. British Journal of Surgery. 2018;105:203–8.

Kent KC. Abdominal Aortic Aneurysms. The New England Journal of Medicine. 2014;371:2101–8.

Howell CCM. Abdominal aortic aneurysm: A ticking time bomb. Journal of American Academy of Physician Assistants. 2016;29(3):32-6.

Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Annals of vascular surgery. 1991;5 (6):491-9.

Kumar Y, Hooda K, Li S, et al. Abdominal aortic aneurysm:pictorial review of common appearances and complications. Annals of Translational Medicine. 2017;5(12):1–7.

National Institute for Health and Care Excellence (NICE). Imaging techniques to diagnose abdominal aortic aneurysms: Abdominal aortic aneurysm: diagnosis and management: Evidence review B. London. 2020.

Benson RA, Poole R, Murray S et al. Screening results from a large United Kingdom abdominal aortic aneurysm screening center in the context of optimizing United Kingdom National Abdominal Aortic Aneurysm Screening Programme protocols. J Vasc Surg. 2015;1–4.

Dent B, Kendall RJ, Boyle AA, Atkinson PR. Emergency ultrasound of the abdominal aorta by UK emergency physicians: a prospective cohort study. Emergency Medicine Journal. 2007 Aug 1;24(8):547-9.

Allison M.A, Hsi S, Wassel C.L et al. Calcified atherosclerosis in different vascular beds and the risk of mortality. Arterioscler Thromb Vasc Biol. 2012;32:140-6.

McEniery CM, McDonnell BJ, So A et al. Aortic calcification is associated with aortic stiffness and isolated systolic hypertension in healthy individuals. Hypertension. 2009;53(3):524-31.

Doherty TM, Fitzpatrick LA, Inoue D et al. Molecular, endocrine, and genetic mechanisms of arterial calcification. Endocrine Reviews. 2004;25(4):629-72.

Buijs RV, Willems TP, Tio RA et al. Calcification as a risk factor for rupture of abdominal aortic aneurysm. European Journal of Vascular and Endovascular Surgery. 2013;46(5):542-8.

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Copyright (c) 2022 May Honey Ohn, Jun Rong Ng, Ng Pey Luen, Khin Maung Ohn


Metrics Loading ...