Adahl Hetherington AH 12342 ABDOMINAL VESSELS Clinical indications and clinical history: A 20-year-old female presented to emergency with

abdominal pain. History of abdominal pain after eating for approximately 5 years. Advised that the episodes more likely after periods of stress and gave examples such as moving house and starting a new job. Previous investigations have included biliary tree disease, liver disease and kidney disease. The referral requested an examination of the abdominal vessels with particular attention paid to the superior mesenteric and celiac trunk arteries. Patient preparation and care: The patient was asked to fast for a minimum four hours prior to the scan to reduce bowel gas and enable better imaging of the abdominal arteries. Warm gel was used for patient comfort. A gown was also provided. After describing the scan to the patient and receiving their consent for the scan to proceed, they were left with instructions to remove clothing and don the gown and to lie on the bed. Scan technique: The scan was performed using a GE Logiq E with a 4Mhz probe. The examination commenced with a B-mode scan of the aorta, celiac axis and superior mesenteric artery. Colour Doppler was used to identify any areas of interest such as aliasing. There was aliasing at the origin of the celiac axis and also the superior mesenteric artery indicating that there were elevated velocities in the blood flow here consistent with probable stenosis. Doppler signals were taken at the origin of the celiac axis were obtained. These velocities were consistent with a stenosis of >75%. This department uses criteria adapted from Moneta, 1991 to grade mesenteric artery stenosis. For the superior mesenteric artery, velocities greater than 275cm/sec are graded as >70% while velocities over 200cm/s in the celiac axis indicate a stenosis of >75% . These criteria are in keeping with the ASUM policy D19. Images and measurements obtained are the same as those outlined by ASUM but the D19 document does not state velocity criteria for grading stenoses. The patient was quite thin and imaging was of good quality. The linear array probe was of too high a frequency to have adequate depth penetration for these vessels, even in this patient. Once the correct depth was set, there were no further changes that needed to have been made. The colour gain and Doppler gain were adjusted as the aliasing was quite significant and a higher PRF was needed to prevent this. At maximum PRF, there was still some Doppler signal aliasing so the baseline was moved downwards. This still left some minor aliasing so the probe frequency was reduced to minimise this. The aliasing was not completely eliminated though a maximum peak systolic velocity was recorded.

Adahl Hetherington AH 12342 Examination of the inferior mesenteric artery is included in the protocol but could not be visualised in this patient. At the conclusion of the exam the patient was given a clean towel to remove the gel. The probe was cleaned first with a clean towel to remove gel then with an alcohol wipe. Finally, the probe was treated with antiseptic spray. Measurements: The velocity of blood flow was measured in the aorta for comparison with the other mesenteric vessels of interest. Velocity measurements were also taken where there was Colour Doppler aliasing. The peak systolic velocity of the celiac axis and the superior mesenteric artery were taken a number of times and the highest two measurements were recorded. This was to ensure that the maximum peak systolic velocity was measured. Normal and abnormal sonographic appearances: The aorta was of normal diameter and the peak systolic velocity was within normal limits . There appeared to be a narrowing of the origin of the celiac axis which was demonstrated using Doppler velocity measurements. The primary diagnosis was median arcuate ligament syndrome which describes a set of symptoms caused by the external compression of the celiac axis . Rutherford states that there is little theoretical justification that symptoms are caused by mechanical compression alone because of the well developed collateral network of vessels supplying the gut. In this case, however there was a concomitant stenosis of the superior mesenteric artery which would have compromised blood flow to the gut and lead to the symptoms of post-prandial pain and weight loss described by the patient . The median arcuate ligament joins the left and right crura of the diaphragm . The compression of the celiac trunk can be the result of either the abnormally inferior insertion of the diaphragm or the abnormally superior origin of the celiac axis . Respiration can exacerbate the effects of a stenosis at end respiration because the diaphragm relaxes bringing the ligament down on the artery . If there is a compression of the celiac trunk by the media arcuate ligament, there is a characteristic hook appearance that can be demonstrated with CT angiography . Clinically, patients are usually young thin women with post-prandial pain and weight loss . There may also be vomiting and epigastric bruit . Differential diagnosis with these symptoms includes appendicitis, cholelithiasis, pancreatitis or abdominal aortic aneurysm After having completed the examination and researching the condition further, it came to my attention that a tilted bed would eliminate the normal compression of the celiac axis at the end of inspiration from the median arcuate ligament. This was not part of our protocol and the patient had been discharged from the hospital to this extension

Adahl Hetherington AH 12342 could not have been carried out. Extending the examination in this way is now part of protocol. Critique of images: 1. Aorta Long

Two Aorta Velocity

Adahl Hetherington AH 12342 The Doppler angle is placed in the centre of the vessel to get the highest velocity measurements. This is because the frictional force of the vessel wall is lowest in the middle of the vessel and so the speed is higher . Three Image showing anatomical relationship

Four SMA Velocity

Adahl Hetherington AH 12342 Five Celiac Axis Velocity

Six Colour Doppler showing aliasing at origin of celiac axis

Aliasing at the origin of the celiac axis is demonstrated in this image. The PRF is set quite high.

Adahl Hetherington AH 12342 Seven Second velocity measurement of celiac axis measurement

Reports/results: A colour duplex scan was performed of the abdominal arteries. The aorta was of normal diameter and displayed normal Doppler signals. There was an apparent narrowing of the origin of the celiac axis with elevated velocities measuring 448cm/sec, consistent with a stenosis of >70%. There were elevated velocities in the proximal superior mesenteric artery of 316cm/sec, consistent with a stenosis of >70%. Legal, ethical and professional considerations: This patient advised that she had been to many different medical professionals in order to get a diagnosis and treatment. She said felt like she was finally getting the right answer. As a professional, you want to make sure that the patient feels like she is getting the best care but also to be careful about providing false hope. Ultrasound was just one of many tests to be carried out prior to any surgical intervention. Understanding that this scan alone was not unequivocal was important so that the patient was not under the impression that what was found was the correct and ultimate diagnosis.

Adahl Hetherington AH 12342 Bibliography: 1. Myers KC, A. Making Sense of Vascular Ultrasound. New York: Oxford University Press; 2004. 2. Rutherford B. Vascular Surgery Pennsylvania: Elsevier Mosby; 2005. 3. Moore K, Daley, A. & Agur, A. Clinically Oriented Anatomy. 5th ed. Baltimore: Wolters Kluwer; 2006. 4. Horton K, Talamini, M., Fishman, E. Median Arcuate Ligament Syndrome: Evaluation with CT Angiography. Radiographics. 2005;25(5):1177-82. 5. Gander S, Mulder, D., Jones, S., Ricketts, J., Soboleski, D., Justinich, C.,. Recurrent abdominal pain and weight loss in an adolescent: Celiac arery compression syndrome. The Canadian Journal of Gastroenterology. 2010;24(2):91-3. 6. Carbonell A, Kercher, K., Heniford, B., Matthews, B. Laparoscopic management of median arcuate ligament syndrome. Surgical Endoscopy. 2004;19. 7. Necas M. Arterial spectral Doppler waveforms: haemodynamic principles and observations. ASUM Ultrasound Bulletin. 2006;9(1):13-22.