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Abdominal > Test 2: Renal and Mesenteric > Flashcards

Test 2: Renal and Mesenteric Flashcards

1
Q

What are the mesenteric vessels?

A
  • Celiac
    • Common hepatic
    • Splenic
  • SMA
  • IMA
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2
Q

What are the two vessel that form the celiac axis?

A

The common hepatic and splenic.

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3
Q

What is the first major branch of the abdominal aorta?

A

The celiac axis.

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4
Q

Where does the celiac axis arise from?

A

It arises off anteriorly, about 1-2 cm below the diaphragm.

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5
Q

What 5 things does the celiac axis supply?

A
  1. Stomach
  2. Duodenum
  3. Liver
  4. Pancreas
  5. Spleen
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6
Q

Where does the superior mesenteric artery arise from?

A
  • It arises approx. 1-2 cm below the celiac axis.
  • Runs anterior and parallel to the aorta.
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7
Q

What 4 things does the SMA supply?

A
  1. Pancreas
  2. Duodenum
  3. Small intestine
  4. Colon
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8
Q

What is the most distal branch?

A

Inferior mesenteric artery.

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9
Q

Where is the IMA located?

A
  • Usually located approx. 1-3 cm proximal to aortic bifurcation.
  • Arises from the anterior surface of the aorta at 1 o’clock.
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10
Q

What does the IMA supply?

A
  • The colon
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11
Q

Approx. how many people are affected by common anatomical variants in the mesenteric vessel?

A

Approx. 20% of general population.

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12
Q

What is the most common (17%) mesenteric vessel variant?

A

Right hepatic artery originates from an artery other than celiac artery.

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13
Q

What are the 4 most common mesenteric anatomical variants?

A
  1. Replaced right hepatic artery originating from the SMA (10-12%)
  2. Replaced common hepatic originating from the SMA (2.5%)
  3. Common hepatic originating from the aorta (2%)
  4. Common origin of celiac and SMA (<1%)
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14
Q

What should be done for patient preparation?

A
  • NPD after midnight
  • Supine with head slightly elevated
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15
Q

What are some normal mesenteric doppler waveforms in the aorta?

A

High resistance

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16
Q

What are some normal mesenteric doppler waveforms in the celiac?

A

Low resistance

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17
Q

What are some normal mesenteric doppler waveforms in the SMA?

A

High resistance IF fasting.

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18
Q

What are some normal mesenteric doppler waveforms in the renals?

A

Low resistance.

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19
Q

What are some normal mesenteric doppler waveforms in the IMA?

A

High resistance IF fasting.

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20
Q

What are some indications for chronic mesenteric ischemia?

A
  • Abdominal pain/cramping associated with eating
  • Abdominal bruit
  • Post-prandial pain
  • Unintended weight loss
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21
Q

In IAC Protocol, what vessels must be assessed?

A
  • Abdominal aorta
  • Celiac axis
  • Common hepatic artery
  • Splenic artery
  • SMA origin
  • Proximal SMA
  • IMA
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22
Q

What must be documented in a mesenteric duplex: IAC protocol?

A
  • Highest PSV
  • Document patency of celiac and SMA
  • Document any conditions of the aorta or great vessels
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23
Q

What is the mesenteric duplex IAC protocal in the celiac artery and what should be documented?

A
  • Document patency
  • Look for high velocities or distrubed flow in the celiac, splenic or hepatic artery.
  • Note common hepatic flow direction
  • Measure PSV in celiac, splenic and hepatic arteries.
  • Document any flow distrubances
  • If stenotic abnormal flow signals are found in the proximal celiac axis, have the patient take a deep breath and hold his breathwhile you take another sample in the celiac axis.
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24
Q

What is the mesenteric duplex protocol for the SMA?

A
  • Document patency
  • Look for high velocities or distrubed flow along as much of the artery as can be seen.
  • Measure PSV in vessels and in any stenotic areas: assess post stenotic flow pattern.
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25
Q

What is the mesenteric duplex protocol in the IMA?

A
  • Locate the IMA if possible
  • Document the patency.
  • Measure the PSV
  • Document any stenosis and post stenotic flow pattern.
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26
Q

What does a normal SMA and IMA signal look like?

A

High resistance.

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27
Q

What does a low resistance signal in the SMA and IMA indicate in a FASTING patient?

A

Mesenteric ischemia.

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28
Q

What indicates a celiac artery stenosis?

A
  • PSV measuring >200 cm/s
  • Post-stenotic turbulence
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29
Q

What indicates a celiac artery occlusion?

A
  • Absence of flow
  • Flow in the common hepatic artery is frequently reversed.
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30
Q

What is normal in the celiac artery?

A
  • <125 cm/s
  • Low resistance waveform.
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31
Q

What indicates greater than/ equal to 70% stenosis?

A
  • >200 cm/s
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32
Q

What is normal in the SMA?

A
  • <125 cm/s
  • High resistance waveform.
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33
Q

What is abnormal that indicates greater than/ equal to a 70% stenosis?

A
  • >275 cm/s
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34
Q

What indicates an occlusion in the SMA?

A
  • Absence of flow prominent IMA may indicate hemosignifcant SMA stenosis or occlusion.
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35
Q

What indicates a celiac occlusion?

A
  • Absence of flow
  • Reversed common hepatic artery flow
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36
Q

What is the diagnostic criteria and interpretation in the IMA?

A
  • No commonly accepted velocity criteria
  • Velocities and doppler waveforms dependent on celiac artery and SMA
  • Assessing for post-stenotic turbulence when elevated velocities are obtained is crucial.
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37
Q

Why might a progressive occlusion of the mesenteric vessels may be relatively asymptomatic?

A

The gut has remarkable ability to develop compensatory collateral flow.

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38
Q

When mesenteric symptoms do occur, what is expected?

A

2 out of the 3 major splanchnic vessels are usually occluded or highly stenosis.

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39
Q

What are some risk factors for mesentric pathology?

A
  • Hypertension
  • Diabetes
  • Smoking
  • High cholestrol.
  • Female
  • Age
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40
Q

Who is more prone susceptible to MALS?

A

More common in younger women

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41
Q

Who is more susceptible to chronic mescenteric ischemia?

A

Elderly.

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42
Q

What are some mesenteric duplex indications?

A
  • Abdominal pain/cramping associated with eating.
  • Abdominal bruit
  • Post-prandial pain
  • Unintended and/or unexplained weight loss.
  • Visceral Artery aneurysm
  • Other gastrointestinal symptoms
  • Post-op
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43
Q

What is the cause of chronic mescenteric ischemia?

A

Atherosclerosis and thrombosis.

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44
Q

What is the cause of acute mesenteric ischemia?

A

Embolism

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45
Q

What is the cause of non-occlusive disease?

A

Low cardiac output

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46
Q

What is the cause of mesenteric vein thrombosis?

A

Hypercoaguability

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47
Q

What is the cause of MALS?

A

The celiac trunk is compressed by the median arcuate ligament which can cause subsequent fibrosis of lumen may occur.

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48
Q

What is the clinical manifestations of acute mesenteric ischemia?

A

Sudden onset of abdominal symptoms and rapid progressions to a life-threatening conditions.

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49
Q

What are the symptoms of acute mesenteric ischemia?

A
  • Abdominal pain
  • Bowel evacuation
  • Abdominal distention
  • fever
  • dehydration
  • GI bleeding
  • Shock
  • Acidosis
  • Death
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50
Q

What is usually involved in acute mesenteric ischemia?

A

SMA

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51
Q

What is the morality rate of acute mesenteric ischemia?

A

70%

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52
Q

What vessels does chronic mesenteric ischemia?

A

It typically involves atleast 2 of the 3 major vessels.

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53
Q

What are the symptoms of chronic mesenteric ischemia?

A
  • Unintended weight loss
  • Fear of food
  • Post-prandial pain
  • Patient avouds food because of pain
  • Diarrhea
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54
Q

What is MALS caused by?

A

It is caused by compression of the median arcuate ligament.

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55
Q

How does MALS normalize?

A

With a deep breath (inspiration)

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56
Q

MALS is typically found in who?

A

Younger women.

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57
Q

What should you do whenever you find an abnormal celiac signal?

A

Have the patient take a deep breath and then evaluate the celiac again with them holding their breath.

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58
Q

What two types of doppler waveforms should you compare in MALS?

A
  1. Deep inspiration
  2. Complete exhalation
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59
Q

Descrie visceral aneurysm?

A
  • Rare
  • Most common site is the splenic artery
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60
Q

Describe a dissection?

A
  • Causes include:
    • athersclerosis
    • FMD
    • mycotic infection
    • trauma
    • connective tissue disorders
  • Most common site is SMA
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61
Q

What PSV in the celiac artery indicate a ≥70% stenosis?

A

PSV ≥ 200 cm/s

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62
Q

What PSV in the SMA indicates a ≥70% stenosis?

A

PSV ≥ 275 cm/s

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63
Q

What EDV in the celiac artery indicates ≥50% stenosis?

A

EDV ≥55 cm/s

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64
Q

What EDV in the SMA indicates a ≥50% stenosis?

A

EDV ≥45 cm/s

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65
Q

What are treatment options in mesenteric pathology?

A
  • Angioplasty and stent placement
  • Arteriotomy
  • Vein patch
  • Decompression of median arcuate ligament
  • Surgery:bypass or endarectomy
  • Bypass: uses either vein or prosthetic material
66
Q

In mesenteric treatment options, what are different options for bypass grafts?

A
  • Supraceliac aorta
  • Infrarenal aorta
  • SMA to celiac
  • Celiac to SMA
  • Iliac to SMA
67
Q

Where should you obtain velocity measurements in a stent/bypass graft?

A
  1. Inflow artery
  2. Proximal anastomosis
  3. Proximal graft or stent
  4. Mid graft or stent
  5. Distal graft or stent
  6. Distal anastomosis
  7. Outflow artery
68
Q

What is the underlying cause for 6% of hypertensive patients?

A

Renal disease.

69
Q

What is the overall accuracy for indentifying and categorizing a stenosis?

70
Q

80-90%

71
Q

What are some other image modalities?

72
Q

Which organ is a highly specialized organ that functions to regulate volume and chemical composition of the body fluids?

73
Q

What are some of the functions of the kidney?

A
  • Reguate volume and chemical composition of body fluids.
  • Produce hormones that regulate BP and make RBC
  • Maintain stable levels of electrolytes
  • Excrete waste
74
Q

Where is the kidney located?

A
  • Located in the retroperitoneum.
    • Dorsal abdominal cavoty
    • @ level of 12th thoracic and 3rd lumbar vertebrae
75
Q

What is the kidney surrrounded by?

A

Fibrous capsule within the perirenal fat.

76
Q

What is a normal kidney length?

77
Q

What happens to the kidneys as one ages?

A

It decreases in size with age.

78
Q

In the kidney, what is the hilum?

A

It is apoint of entry/exit for renal artery, renal vein, and ureter.

79
Q

In the kidney, what is the sinus?

A

Cavity containing renal artery, renal vein, and collecting and lymphatic system.

80
Q

In the kidney, what is the parenchyma?

A

It is the tissue that the renal is comprised of.

81
Q

What does the parenchyma consist of?

A
  • Cortex
  • Medulla
82
Q

What does the glomerulus do?

A

It filters the blood.

83
Q

What does the tubule?

A

It reabsorbs and secretes fluid and electrolytes to adjust the urinary composition as necessary to maintain homeostasis of bodily fluids.

84
Q

Where is the glomeruli located?

A

It is located in the cortex of the kidney (outer one third of the kidney)

85
Q

What does the inner 2/3 of kidney consist of?

A

It consist of dark, striated areas (pyramids) and intervening renal columns.

Together they comprise the medulla.

86
Q

Where is the renal hilum found?

A

It is found medially and is the point of entry for the arteries, veins, nerves and the exist of the ureter.

87
Q

What is a dromedary hump?

A
  • It is a focal bulge
  • Most oftenly seen in left kidney
  • Normal kidney appearance
88
Q

What is a horseshoe kidney?

A
  • Usually connected at the lower poles
  • Occurs in <1% of population
89
Q

What is a common kidney variant?

A

Hydroplastic kidney

90
Q

What is a hydroplastic kidney?

A

It is a congenitally small kidney that may be normal or incompletely developed.

91
Q

What is hydronephrosis?

A

It is a partial or complete urinary tract obstruction.

92
Q

Which segements of the kidney does hydronephrosis affect?

A
  • Bladder
  • Ureter
  • Urethral
  • Intrarenal
    • stones
93
Q

What are the symptoms of renal calculi?

A
  • Loin pain
  • Hematuria (blood in urine)
  • UT obstruction
94
Q

What are the duplex characterisitcs of renal cysts?

A
  • Hypoechoic
  • Have thing, smooth. and clearly defined margins
  • Exhibit acoutstic enhancement posterior to the cyst
  • Increase incidence with (50% over 50)
95
Q

What kind of disease is polycystic kidney disease?

A

Autosomal-dominant.

96
Q

What causes polycystic kidney disease?

A

Genetics condition

97
Q

What is polycystic kidney disease predipose a patient to?

A

End-stage renal disease.

98
Q

What symptoms are associated with polycystic kidney disease?

A
  • Loin pain
  • Headaches
  • Hematuria
99
Q

What other cyst are usually common with PKD?

A

Hepatic cyst

100
Q

How do renal masses present themselves on duplex?

A
  • B-mode: demonstrates echoes within lumen
  • Color image demonstrates color flow within mass
101
Q

What is the protocol for doing a renal exam?

A
  • Measure the kidney length
  • Obtain signals from the distal renal artery and the renal vein
  • Obtain doppler signals from the mid, upper and lower poles of the kidney.
    • measure PSV/EDV
    • RI
  • Document any incidental findings
102
Q

What is Acceleration Index (AI)?

A

It is the slope of the systolic upstroke divided by the transmitted frequency

103
Q

What is Acceleration Time (AT)?

A

It is the time interval between the onset of systole and the initial compliance peak.

104
Q

What does the resistive index (RI) indicate?

A

It indicates the state of the parenchyma in the kidney

105
Q

What does a low RI indicate?

A

Low resistance flow

106
Q

What does a high RI indicate?

A

It indicates high resistance flow which indicates renal parenchymal disease

107
Q

What RI signifies medical renal disease or renal parenchymal disease?

108
Q

What does RI give information about?

A

Intra-renal flow.

May be within normal limits even with a hemodynamically significant RAS

109
Q

How do you find the RI?

A
  • use 0° to isonate arteries within kidney
  • Obatin doppler signals and measure PSV and EDV in upper, mid. and lower poles.
  • Some labs may require the cortex and medulla
  • Average together for final number
110
Q

What are the characterisitics of acute renal failure (ARF)?

A
  • Normal size kidney size and texture
  • High resistance flow in kidney
111
Q

What are the characterisitics of chronic renal failure?

A
  • Small kidney size
  • Thinning of the cortex and diffuse chnages in kidney texture
  • High resistance flow in end stages
112
Q

It is estimated that how many people in the US population have hypertension?

A

50 million

113
Q

How many hypertensive patient have an underlying renal disease?

114
Q

Renal artery disease represents the most common correctable cause of ____________

A

Hypertension

115
Q

What can cause renal ischemia?

A

A stenosis or occlusion of the main renal artery

116
Q

What does a renal ischemia from a renal stenosis/occlusion trigger?

A

It triggers the renin-angiotensin mechanism to increase flow to the kidney.

117
Q

Renal artery stenosis can cause or contribute to what?

A

Renal insuffieciency by causing renal parenchymal damage.

118
Q

What are 4 clinical maifestations observed in renal artery stenosis?

A
  • Asymptomatic “incidental RAS”
  • Renovascular hypertension
  • Ischemic nephropathy
  • Accelerated CV disease
    • CHF
    • Stroke
    • Secondary aldosteronism
119
Q

Where does the renal artery originate?

A

Inferior to SMA

120
Q

Which renal is longer?

A

RRA is longer in length than the LRA

121
Q

how does the right renal courses in regards to the RRV and IVC?

A

RRA courses posteriorly to RRV and IVC

122
Q

How does the LRA course in regards to the LRV?

A

LRA courses posteriorly to LRV

123
Q

Where does the LRV course?

A

It courses between abdominal aorta and SMA

124
Q

Duplicate main arteries and polar accessory renals occur in _______ of patients/

125
Q

What is the most common variant?

A

Most renal arteries arise below the main renal artery and terminate at polar surfaces of kidney instead of hilum.

126
Q

Where can accessory renal arteries arise from?

A

The aorta or iliac arteries.

127
Q

In which renal do these variants more commonly occur in?

A

Occurs more frequently on the left than right.

128
Q

WHat is included in a patients clinical history?

A
  • HTN
  • Abnormal urinalysis
  • Hematuria
  • CHF
  • Renal failure
  • Flash pulmonary edema.
129
Q

What are some renal vasculature pathology?

A
  • Athersclerosis-stenosis or occlusion
  • Fibromuscular dysplasia
  • Embolism
  • Aneurysm
  • AV fistula
  • External compression
  • Vasculitis
130
Q

What are some common risk factors for renal disease?

A
  • Age
  • Hypertension
  • Diabetes
  • SMoking
  • Hyperlipidemia
  • Obesity
  • Coronary artery disease
  • Race
  • Family Hx
131
Q

What are some indications for a renal exam?

A
  • Sudden onset or worsening of chronic hypertension
  • Elevated BUN levels (blood-urea-nitrogen), azotemia.
  • Cystic kidney disease
  • Atrophic kidney
  • Aneurysm
  • Pre- and/or post-intervention
  • Abdominal bruit
  • Hypertension ina young patient.
132
Q

How should you preform a renal artery duplex?

A
  • Patient supine
  • Evaluate the aorta, sma, and celiac arteries
  • Obtain representative doppler signals from each.
  • DOcument any abnormalities
  • Obtain aortic PSV at level of SMA
    • Used to calcuate the renal-aortic-ratio (RAR)
133
Q

Where does the RRA arise from in relation to the aorta?

A

Arises from the anterior aorta at about 10-11 o’clock.

Below LRV

134
Q

Where does the LRA arise from in relation to the aorta?

A

It arises from the posterior/lateral aorta about 4-5 o’clock.

135
Q

Where do you want to assess each renal artery from?

A

From its origin to the hilum of the kidney.

136
Q

Where do you want to obatin represenative doppler signals in the renals?

A
  • Ostium
  • Proximal
  • Mid
  • Distal
137
Q

What do you want to look out for when scanning a renal artery?

A

Look for areas of high velocity or flow distrubances that may he related to a stenosis.

138
Q

How do you want to preform a renal exam on a patient in a lateral decubitus position?

A
  • Measure the kidney in long
  • Obtain signals from the renal parenchyma in the upper, mid, and lower poles using 0 degree insonation.
  • Obtain angle-corrected velocities in the distal renal artery and a doppler signal from the renal vein.
139
Q

What is a normal PSV in the renal arteries?

A

90-120 cm/sec

140
Q

What happens to the PSV and EDV from the renal artery to cortex?

A

It decreases.

141
Q

Typical velocities for distal RA?

A

70-90 cm/s

142
Q

Typical velocities for the renal sinus?

A

30-50 cm/s

143
Q

Typical velocities for renal cortex?

A

10-20 cm/s

144
Q

What is a hemodynamically significant renal artery stenosis considered to be?

A

60% or greater

145
Q

How do you calculate the Renal Aortic Ratio?

A

PSV of renal artery/ PSV of aorta =RAR

  • PSV of aorta usually 80-100 cm/s
  • Velocities in aorta that are above or below the mean may make RAR inaccurate
146
Q

What is normal diagnostic criteria in the renal arteries?

A
  • Sharp upstroke with low resistance forward flow in diastole
  • Peak systolic velocities of less than 180 cm/s
  • Renal/aortic ratio less than 3.5
147
Q

What is the diagnostic criteria for a hemodynamically insignificant stenosis of less than 60%?

A
  • Peak systolic velocity of 180 cm/s or greater.
  • Renal/aortic ratio of less than 3.5
148
Q

What is the diagnostic criteria that is hemodynamically significant disease of 60% or greater?

A
  • Renal/aortic ratio of 3.5 or greater
  • PSV greater than 180 cm/s
  • Post-stenotic turbulence.
149
Q

What is the diagnostic criteria of a renal artery occlusion?

A
  • No arterial signal in renal artery
  • Kidney size of less than 8 or 9 cm
  • If flow detected in kidney, usually less than 10 cm/s
150
Q

What is FMD?

A
  • Non-athersclerotic disease
  • May affect bilateral renal arteries, but more common on right
  • Typically affects younger females (25-50 Y/O)
  • Affect internal carotid arteries
    • Mid and distal segments
  • Affects ICA
    • Mid and distal segments
  • “string of beads” appearance
151
Q

When is FMD suspected?

A
  • When velocities increase in the mid/distal portions of the RA
  • Criteria is similar to other arterial segements
    • PSV doubles the proximal arterial segments PSV
152
Q

What is an indirect method of detecting renal artery stenosis?

A
  • Obtain signals from the different poles of the kidney and evaluate for acceleration time
  • Normal signals have rapid acceleration time
  • Patients with renal artery stenosis will have a slower acceleration time, described as the tardus parvus waveform.
153
Q

Describe renal artery aneurysms

A
  • More often saccular than fusiform
  • Typically occurs before reaching the parenchyma
154
Q

What is nutcracker syndrome?

A

It is the compression of the left renal vein as it passes between the SMA and aorta

155
Q

What does Nut cracker syndrome for to the venous velocities and diameter?

A
  • Increased venous velocities at site of compression
  • Venous diameter may be increased distal to compression point
156
Q

What are the symptoms associated with nutcracker syndrome?

A
  • May be completely asymptomatic
  • Microhematuria
  • Left flank pain
157
Q

What are some therapeutic options for renal disease?

A
  • Medical therapy
    • anti-hypertensive medication
  • Surgical
    • Endarectomy
    • Bypass
      • Aorto-renal
      • Hepato-renal
      • Spleno-renal
  • Endovascular
    • Angioplasty
    • Stent
158
Q

What are some anti-hypertensive medicatiom?

A
  • Diuretics
  • ACE inhibitors
  • Beta-blockers
  • Calcium-channel blockers
159
Q

What do diuretics?

A

Increase urine production to remove water and sodium

160
Q

What do ACE inhibitors?

A

Angiotensin is an enzymes that, when activated, causes blood vessels to constrict.→Results in high BP and strain on heart→ACE inhibitors prevent this by dialating blood vessels and lowering BP

161
Q

What do beta blockers do?

A

blocks beta receptors

162
Q

What do calcium channel blockers do?

A

SLows the rate in which calcium passes into the heart muscle and into the vessel walls.

This relaxes the vessel, lowering the BP

Abdominal (6 decks)

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