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Abdominal Bruit Preso 2
 

Abdominal Bruit Preso 2

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Abdominal Bruit Detection / Significance

Abdominal Bruit Detection / Significance

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Abdominal Bruit Preso 2 Abdominal Bruit Preso 2 Presentation Transcript

  • Is Listening for Abdominal Bruits Useful in the Evaluation of Hypertension Presented by James Ratliff, M.D. April 18, 2008
  • Outline for Today’s Talk
    • Review Origins of Abdominal Bruits
    • How to Examine Abdominal Bruits
    • Prevalence of Abdominal Bruits
    • Precision of Abdominal Auscultation
    • Statistics Overview
    • Accuracy of Abd Auscultation in Hypertension
    • Auscultatory Characteristics of Bruits
    • Prognosis of Patients with Htn / Bruit
    • The Bottom Line
  • Anatomic and Physiologic Origins of an Abdominal Bruit
    • Physiologic Etiology
      • Turbulent Flow Within a Vessel
    • Pitch and Radiation
      • Determined by the Flow and Direction
    • Can be Intrinsic or Extrinsic to the Abdomen
      • Usually Arising from the Abdomen
      • Inguinal Area
      • Retroperitoneum
      • Thorax
  • Abdominal Bruits - Examination
    • Patient in a Supine Position
    • Auscultate
      • Epigastrium
      • All Four Quadrants Anteriorly
      • Spine / Flank Posteriorly
        • Between T-12 and L-2
      • Correlate to the Cardiac Cycle
        • Carotid Upstroke
  • Abdominal Bruits - Examination
    • Epigastric Region
      • Renovascular Disease
      • Pancreatic Neoplasm
      • Innocent Bruit
    • Right Upper Quadrant
      • Hepatic Carcinoma
    • Left Upper Quadrant
      • Splenic Arteriovenous Fistula
    • Periumbilic Bruits
      • Mesenteric Ischemia
      • Abdominal Aortic Aneurysm
      • Elder Populations
  • Abdominal Bruits - Prevalence
  • Abdominal Bruits - Prevalence
  • Abdominal Bruits Prevalence
  • Abdominal Bruits - Precision
    • No Extensive Studies Performed
    • Watson and Williams
      • 92.5% Agreement
      • Study Conducted 149 / 161
      • Identified an Abdominal Bruit in Patients with Celiac Artery Compression
      • Prospective Study
      • Required Standardization of Observers
      • Claims “Appropriate” Degree of Precision
  • Statistics Review Accuracy = TRUE POSITIVES + TRUE NEGATIVES True Positives+False Positives+False Negatives+True Negatives Accuracy ↓ Specificity ↓ Sensitivity -> Negative Predictive Value True Negative False Negative Negative -> Positive Predictive Value False Positive True Positive Positive Test False True Condition (e.g. Disease) As determined by "Gold" standard
  • Abdominal Bruits - Accuracy
  • Abdominal Bruits - Accuracy
    • Grim et. Al. 1979
    • Evaluated 64 Patients with Renovascular Hypertension
      • Defined as an Abnormal Angiogram with a Renal Vein Renin Ratio of > 1.5
      • 25 of which had Combined Systolic – Diastolic Abdominal Bruits
      • This Equates to 39% Sensitivity CI 95% and
      • 2 of 199 Patients with a Normal Arteriogram had a Systolic – Diastolic Bruit
      • This Equates to Specificity of 99% CI 95%
    RV HTN+ RV HTN- Sys/Dia Bruit + Sys/Dia Bruit - Sensitivity Specificity 197 39 2 25
  • Abdominal Bruits - Accuracy
    • Fenton et. Al. 1966
    • Evaluated 27 Patients with Renovascular Hypertension
      • Defined as an Abnormal Angiogram with a Renal Vein Renin Ratio of > 1.5
      • Further Defined as any Patient detected with an Epigastric / Flank Bruit in the Presence of Hypertension Undergoing Arteriography
      • 17 of which had Combined Systolic – Diastolic Abdominal Bruits
      • This Equates to 63% Sensitivity CI 95%
      • 9 of 91 Patients with a Normal Arteriogram had a Systolic – Diastolic Bruit
      • This Equates to Specificity of 90% CI 95%
    RV HTN+ RV HTN- ANY Bruit + ANY Bruit - Sensitivity Specificity 82 10 9 17
  • Abdominal Bruits – Accuracy Continued
    • These Data Support the finding
      • The presence of any Systolic Bruit
        • Has the LOWEST LR of the Studies
        • LR = 2.1 vs 3.5 if Absent
      • The presence of ANY Epigastric / Flank / Systolic Bruit
        • Has a LOW LR of being predictive for Renovascular Hypertension
        • LR = 6.4 if present vs 0.4 if Absent 95% CI
      • The Presence of Both a Systolic and Diastolic
        • Has a HIGHER LR
        • LR = 39 if present vs 0.6 if Absent 95 % CI
      • While the Absence of a Systolic – Diastolic Bruit did not rule out Renovascular Hypertension – the Presence of this type of Bruit helped to Suggest it may be in the Differential
  • Abdominal Bruits – Accuracy Continued
    • There is a substantial Prevalence of Systolic Bruits in Young Healthy Patients
    • Bruits are Further Increased in Hypertensive Patients with Documented Renovascular Disease
    • In the Limited Rigorously Assessed Tests Available
      • Sensitivity Ranged 20% to 77.7%
      • Specificity Ranged 63.6 % to 90%
    • Systolic – Diastolic Bruits
      • Uncommon in Healthy Patients / Essential Hypertension
      • More Common in Renovascular Disease
      • Increased Prevalence of all Bruits in Fibromuscular Disease
  • Abdominal Bruits Auscultatory Characteristics
    • Moser and Caldwell Study of Bruit:
      • Pitch / Intensity / Location
      • Demonstrated an INCREASED Prevalence of Renal Artery Disease in the Presence of a High Pitched Bruit vs Medium / Low Pitched Bruit
        • 86.6% vs 57.1%
        • Julius and Steward reported and Increased Prevalence of High Pitched Bruits of 64.3%
      • Intensity
        • Loud 80.1% or 17 of 21
        • Quiet 55% or 16 of 29
  • Abdominal Bruits Auscultatory Characteristics
    • Location
        • Correctly Localized in 6 / 13 Patients with Isolated Single Vessel Disease which correlates to a 46.2% Success Rate
        • Eppier et al
          • 70% of Fibromuscular Disease Patients
          • 43% of Renovascular Disease Patients
    • Julius and Steward 1967
      • Direct Ascultation of Renal Artery During Surgery
        • 18 Patients with Pre-Surgical Bruits
          • 9 Were Accurately Confined to the Correct Artery
          • 7 Demonstrated Additional Extra Renal Bruits
          • 2 Had Bruits Unrelated to the Renal Artery
  • Abdominal Bruits Prognosis
    • Eppier et al
      • 84% of Patients with Systolic – Diastolic Bruits had FAVORABLE Surgical Results as Compared to 55% of Patients Demonstrating Only a Systolic Bruit or No Bruit at All
    • Simon et al found NO Prognostic Importance in Patients with Abdominal Bruits
  • Abdominal Bruits The Bottom Line
    • Based on the High Prevalence of Abdominal Bruits - a Systolic Bruit Found in an Otherwise Healthy Younger Patient
      • NO Further Workup is Indicated
    • Based on the High Specificity of a Systolic-Diastolic Bruit in a Hypertensive Patient
      • Suggestive of Renovascular Hypertension
      • Subsequent Investigation Should take into Consideration the COST and POTENTIAL BENEFIT of further Action
  • Abdominal Bruits The Bottom Line
    • Based on the Lack of Evidence to Support Characterizing Bruits as to Pitch / Intensity and Location
      • Should Only be Identified as Systolic vs Diastolic
    • No Data Currently Exists to Provide any Prognostic Implication for the Presence of an Abdominal Bruit
  • Abdominal Bruits The Bottom Line Summary
    • The paper reviewed available studies pertaining to Abdominal Bruits. The findings presented suggest there is “LITTLE VALUE” in routinely ascultating the Abdomen of a Healthy Asymptomatic Population. However, in a symptomatic patient, the presence of a Systolic-Diastolic abdominal bruit would provide SUPPORTIVE EVIDENCE of an underlying diagnosis of renovascular disease potentially warranting more aggressive investigation
  • Questions and Answers
  • References
    • JAMA, October 25,1995-Vol 274, No. 16
      • J.M. Turnbull, MD, FRCP “ Is Listening for Abdominal Bruits Useful in the Evaluation of Hypertension?”
    • http://en.wikipedia.org