Abdominal Bruit Preso 2

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Abdominal Bruit Detection / Significance

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  • Abdominal Bruit Preso 2

    1. 1. Is Listening for Abdominal Bruits Useful in the Evaluation of Hypertension Presented by James Ratliff, M.D. April 18, 2008
    2. 2. Outline for Today’s Talk <ul><li>Review Origins of Abdominal Bruits </li></ul><ul><li>How to Examine Abdominal Bruits </li></ul><ul><li>Prevalence of Abdominal Bruits </li></ul><ul><li>Precision of Abdominal Auscultation </li></ul><ul><li>Statistics Overview </li></ul><ul><li>Accuracy of Abd Auscultation in Hypertension </li></ul><ul><li>Auscultatory Characteristics of Bruits </li></ul><ul><li>Prognosis of Patients with Htn / Bruit </li></ul><ul><li>The Bottom Line </li></ul>
    3. 3. Anatomic and Physiologic Origins of an Abdominal Bruit <ul><li>Physiologic Etiology </li></ul><ul><ul><li>Turbulent Flow Within a Vessel </li></ul></ul><ul><li>Pitch and Radiation </li></ul><ul><ul><li>Determined by the Flow and Direction </li></ul></ul><ul><li>Can be Intrinsic or Extrinsic to the Abdomen </li></ul><ul><ul><li>Usually Arising from the Abdomen </li></ul></ul><ul><ul><li>Inguinal Area </li></ul></ul><ul><ul><li>Retroperitoneum </li></ul></ul><ul><ul><li>Thorax </li></ul></ul>
    4. 4. Abdominal Bruits - Examination <ul><li>Patient in a Supine Position </li></ul><ul><li>Auscultate </li></ul><ul><ul><li>Epigastrium </li></ul></ul><ul><ul><li>All Four Quadrants Anteriorly </li></ul></ul><ul><ul><li>Spine / Flank Posteriorly </li></ul></ul><ul><ul><ul><li>Between T-12 and L-2 </li></ul></ul></ul><ul><ul><li>Correlate to the Cardiac Cycle </li></ul></ul><ul><ul><ul><li>Carotid Upstroke </li></ul></ul></ul>
    5. 5. Abdominal Bruits - Examination <ul><li>Epigastric Region </li></ul><ul><ul><li>Renovascular Disease </li></ul></ul><ul><ul><li>Pancreatic Neoplasm </li></ul></ul><ul><ul><li>Innocent Bruit </li></ul></ul><ul><li>Right Upper Quadrant </li></ul><ul><ul><li>Hepatic Carcinoma </li></ul></ul><ul><li>Left Upper Quadrant </li></ul><ul><ul><li>Splenic Arteriovenous Fistula </li></ul></ul><ul><li>Periumbilic Bruits </li></ul><ul><ul><li>Mesenteric Ischemia </li></ul></ul><ul><ul><li>Abdominal Aortic Aneurysm </li></ul></ul><ul><ul><li>Elder Populations </li></ul></ul>
    6. 6. Abdominal Bruits - Prevalence
    7. 7. Abdominal Bruits - Prevalence
    8. 8. Abdominal Bruits Prevalence
    9. 9. Abdominal Bruits - Precision <ul><li>No Extensive Studies Performed </li></ul><ul><li>Watson and Williams </li></ul><ul><ul><li>92.5% Agreement </li></ul></ul><ul><ul><li>Study Conducted 149 / 161 </li></ul></ul><ul><ul><li>Identified an Abdominal Bruit in Patients with Celiac Artery Compression </li></ul></ul><ul><ul><li>Prospective Study </li></ul></ul><ul><ul><li>Required Standardization of Observers </li></ul></ul><ul><ul><li>Claims “Appropriate” Degree of Precision </li></ul></ul>
    10. 10. 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 &quot;Gold&quot; standard
    11. 11. Abdominal Bruits - Accuracy
    12. 12. Abdominal Bruits - Accuracy <ul><li>Grim et. Al. 1979 </li></ul><ul><li>Evaluated 64 Patients with Renovascular Hypertension </li></ul><ul><ul><li>Defined as an Abnormal Angiogram with a Renal Vein Renin Ratio of > 1.5 </li></ul></ul><ul><ul><li>25 of which had Combined Systolic – Diastolic Abdominal Bruits </li></ul></ul><ul><ul><li>This Equates to 39% Sensitivity CI 95% and </li></ul></ul><ul><ul><li>2 of 199 Patients with a Normal Arteriogram had a Systolic – Diastolic Bruit </li></ul></ul><ul><ul><li>This Equates to Specificity of 99% CI 95% </li></ul></ul>RV HTN+ RV HTN- Sys/Dia Bruit + Sys/Dia Bruit - Sensitivity Specificity 197 39 2 25
    13. 13. Abdominal Bruits - Accuracy <ul><li>Fenton et. Al. 1966 </li></ul><ul><li>Evaluated 27 Patients with Renovascular Hypertension </li></ul><ul><ul><li>Defined as an Abnormal Angiogram with a Renal Vein Renin Ratio of > 1.5 </li></ul></ul><ul><ul><li>Further Defined as any Patient detected with an Epigastric / Flank Bruit in the Presence of Hypertension Undergoing Arteriography </li></ul></ul><ul><ul><li>17 of which had Combined Systolic – Diastolic Abdominal Bruits </li></ul></ul><ul><ul><li>This Equates to 63% Sensitivity CI 95% </li></ul></ul><ul><ul><li>9 of 91 Patients with a Normal Arteriogram had a Systolic – Diastolic Bruit </li></ul></ul><ul><ul><li>This Equates to Specificity of 90% CI 95% </li></ul></ul>RV HTN+ RV HTN- ANY Bruit + ANY Bruit - Sensitivity Specificity 82 10 9 17
    14. 14. Abdominal Bruits – Accuracy Continued <ul><li>These Data Support the finding </li></ul><ul><ul><li>The presence of any Systolic Bruit </li></ul></ul><ul><ul><ul><li>Has the LOWEST LR of the Studies </li></ul></ul></ul><ul><ul><ul><li>LR = 2.1 vs 3.5 if Absent </li></ul></ul></ul><ul><ul><li>The presence of ANY Epigastric / Flank / Systolic Bruit </li></ul></ul><ul><ul><ul><li>Has a LOW LR of being predictive for Renovascular Hypertension </li></ul></ul></ul><ul><ul><ul><li>LR = 6.4 if present vs 0.4 if Absent 95% CI </li></ul></ul></ul><ul><ul><li>The Presence of Both a Systolic and Diastolic </li></ul></ul><ul><ul><ul><li>Has a HIGHER LR </li></ul></ul></ul><ul><ul><ul><li>LR = 39 if present vs 0.6 if Absent 95 % CI </li></ul></ul></ul><ul><ul><li>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 </li></ul></ul>
    15. 15. Abdominal Bruits – Accuracy Continued <ul><li>There is a substantial Prevalence of Systolic Bruits in Young Healthy Patients </li></ul><ul><li>Bruits are Further Increased in Hypertensive Patients with Documented Renovascular Disease </li></ul><ul><li>In the Limited Rigorously Assessed Tests Available </li></ul><ul><ul><li>Sensitivity Ranged 20% to 77.7% </li></ul></ul><ul><ul><li>Specificity Ranged 63.6 % to 90% </li></ul></ul><ul><li>Systolic – Diastolic Bruits </li></ul><ul><ul><li>Uncommon in Healthy Patients / Essential Hypertension </li></ul></ul><ul><ul><li>More Common in Renovascular Disease </li></ul></ul><ul><ul><li>Increased Prevalence of all Bruits in Fibromuscular Disease </li></ul></ul>
    16. 16. Abdominal Bruits Auscultatory Characteristics <ul><li>Moser and Caldwell Study of Bruit: </li></ul><ul><ul><li>Pitch / Intensity / Location </li></ul></ul><ul><ul><li>Demonstrated an INCREASED Prevalence of Renal Artery Disease in the Presence of a High Pitched Bruit vs Medium / Low Pitched Bruit </li></ul></ul><ul><ul><ul><li>86.6% vs 57.1% </li></ul></ul></ul><ul><ul><ul><li>Julius and Steward reported and Increased Prevalence of High Pitched Bruits of 64.3% </li></ul></ul></ul><ul><ul><li>Intensity </li></ul></ul><ul><ul><ul><li>Loud 80.1% or 17 of 21 </li></ul></ul></ul><ul><ul><ul><li>Quiet 55% or 16 of 29 </li></ul></ul></ul>
    17. 17. Abdominal Bruits Auscultatory Characteristics <ul><li>Location </li></ul><ul><ul><ul><li>Correctly Localized in 6 / 13 Patients with Isolated Single Vessel Disease which correlates to a 46.2% Success Rate </li></ul></ul></ul><ul><ul><ul><li>Eppier et al </li></ul></ul></ul><ul><ul><ul><ul><li>70% of Fibromuscular Disease Patients </li></ul></ul></ul></ul><ul><ul><ul><ul><li>43% of Renovascular Disease Patients </li></ul></ul></ul></ul><ul><li>Julius and Steward 1967 </li></ul><ul><ul><li>Direct Ascultation of Renal Artery During Surgery </li></ul></ul><ul><ul><ul><li>18 Patients with Pre-Surgical Bruits </li></ul></ul></ul><ul><ul><ul><ul><li>9 Were Accurately Confined to the Correct Artery </li></ul></ul></ul></ul><ul><ul><ul><ul><li>7 Demonstrated Additional Extra Renal Bruits </li></ul></ul></ul></ul><ul><ul><ul><ul><li>2 Had Bruits Unrelated to the Renal Artery </li></ul></ul></ul></ul>
    18. 18. Abdominal Bruits Prognosis <ul><li>Eppier et al </li></ul><ul><ul><li>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 </li></ul></ul><ul><li>Simon et al found NO Prognostic Importance in Patients with Abdominal Bruits </li></ul>
    19. 19. Abdominal Bruits The Bottom Line <ul><li>Based on the High Prevalence of Abdominal Bruits - a Systolic Bruit Found in an Otherwise Healthy Younger Patient </li></ul><ul><ul><li>NO Further Workup is Indicated </li></ul></ul><ul><li>Based on the High Specificity of a Systolic-Diastolic Bruit in a Hypertensive Patient </li></ul><ul><ul><li>Suggestive of Renovascular Hypertension </li></ul></ul><ul><ul><li>Subsequent Investigation Should take into Consideration the COST and POTENTIAL BENEFIT of further Action </li></ul></ul>
    20. 20. Abdominal Bruits The Bottom Line <ul><li>Based on the Lack of Evidence to Support Characterizing Bruits as to Pitch / Intensity and Location </li></ul><ul><ul><li>Should Only be Identified as Systolic vs Diastolic </li></ul></ul><ul><li>No Data Currently Exists to Provide any Prognostic Implication for the Presence of an Abdominal Bruit </li></ul>
    21. 21. Abdominal Bruits The Bottom Line Summary <ul><li>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 </li></ul>
    22. 22. Questions and Answers
    23. 23. References <ul><li>JAMA, October 25,1995-Vol 274, No. 16 </li></ul><ul><ul><li>J.M. Turnbull, MD, FRCP “ Is Listening for Abdominal Bruits Useful in the Evaluation of Hypertension?” </li></ul></ul><ul><li>http://en.wikipedia.org </li></ul>

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