Auscultation of Abdominal Arterial Murmurs

Auscultation of abdominal arterial murmurs

C. ARTHUR MYERS, D.O.,° Flint, Michigan publications. Goldblatt's4 work on renal hypertension has stimulated examiners to begin performing The current interest in the diagnostic value of ab- auscultation for renal artery bruits in their hyper- dominal arterial bruits is evidenced by the number tensive patients. of papers and references to the subject appearing in Stenosis, either congenital or acquired, and aneu- the recent literature. When Vaughan and Thoreki rysms are responsible for the vast majority of audi- published an excellent paper on abdominal auscul- ble renal artery bruits (Fig. 2). One should be tation in 1939, the only reference they made to highly suspicious of a renal artery defect in a hy- arterial murmurs was that of the bruit of abdominal pertensive patient with an epigastric murmur. Moser aortic aneurysm. In more recent literature, however, and Caldwell5 have produced the most comprehen- there is evidence of increased interest in auscultat- sive work to date on auscultation of the abdomen ing the abdomen for murmurs arising in the celiac, in renal artery disease. In their highly selective superior mesenteric, splenic, and renal arteries. series of 50 cases of abdominal murmurs in which The purpose of this paper is to review some of aortography was performed, renal artery disease the literature referable to the subject of abdominal was diagnosed in 66 per cent of cases. Their con- murmurs, to present some cases, and to stimulate clusions were that when an abdominal murmur of interest in performing auscultation for abdominal high pitch is found in a patient with hypertension, bruits as a part of all physical examinations. Since even though the intravenous pyelogram is normal, most clinicians are aware of the sounds produced renal artery stenosis is a good possibility. This is by a diseased abdominal aorta or iliac artery,2,3 not to imply that if the murmur is not high pitched discussion here will be limited to those murmurs it is not due to renal artery disease. However, a arising from the smaller arteries named above high-pitched bruit should raise one's index of sus- (Fig. 1). picion. Gilliland, Deller, and Ha118 have reported the case of a 27-year-old hypertensive male, Renal artery subsequently found to have unilateral renal artery steno- Those murmurs produced by renal artery disease sis, with a loud bruit audible over the left upper have received the most attention in the current part of the abdomen and flank. Verstraete and as- sociates7 found bruits in 10 patients out of a total Presented at the Eastern Study Conference of the American College of Osteopathic Internists, Philadelphia, March 15, 1963. Dr. Myers of 14 with renal artery defects. In another series of is a resident in the Department of Internal Medicine, Flint Osteo- 22 cases of renal artery disease,8 systolic bruits pathic Hospital, of which Dr. E. E. Congdon is chairman. were found in 10 patients. °Address, Flint Osteopathic Hospital, 3921 Beecher Rd. Morris and DeBakey9 state, "The physical ex-

326/46 above and lateral to the umbilicus, and are occa- sionally heard near the costovertebral angle. Deep, CELIAC firm pressure on the stethoscope is required in most ARTERY cases. In this hospital, we have found a DeLee- Hillis head stethoscope to be valuable in eliciting these bruits (Fig. 3).

LEFT GASTRIC ARTERY

HEPATIC ARTERY

SPLENIC ARTERY SUPERIOR MESENTERIC ARTERY mixonsoff

RENAL ARTERIES Fig. I. Some smaller arteries in which abdominal murmurs can arise. Fig. 3. The DeLee-Hillis head stethoscope, useful in auscultation of abdominal bruits. amination of the renovascular hypertensive patient is not often distinctive, although nearly 25 per cent Following is a case of renal artery aneurysm in of such cases do have upper abdominal or flank which a murmur was present, which was defini- murmurs created by renal arterial narrowing." They tively diagnosed by lumbar aortography. caution, however, that many of these patients have arteriosclerotic changes in other vessels, which may Case 1 • A 37-year-old white woman was admitted produce murmurs indistinguishable from those aris- to the hospital with complaints of abdominal and ing in the renal artery. Other studies of renal artery back pain. The back pain was constant in charac- disease mention briefly the presence of abdominal 2,10-12 ter and located in the thoracolumbar area on the bruits right. The abdominal pain was generalized and Most writers agree that the murmurs may be mild. She had had four such episodes within the systolic or continuous, are usually elicited just past year, the present one beginning 6 days prior to admission. The episodes were accompanied by chills, fever, and dysuria. There was no history of hypertension. Pertinent physical findings were pain on palpation on the right side of the abdomen and a positive Lloyd's sign bilaterally, more pronounced on the right. On auscultation of the abdomen, a high-pitched systolic murmur of moderate intensity was heard, 1 inch above and to the right of the umbilicus. An intravenous pyelogram showed an "imposing defect on the superior margin of the right renal pelvis adjacent to the right superior major calyx" ( Fig. 4). A retrograde pyelogram was performed, revealing a "partially calcified filling defect in the upper portion of the right renal pelvis" (Fig. Fig. 2. Bruits of the renal artery in a majority of cases are 5). Translumbar aortography was done and re- caused either by aneurysm (left) or by congenital or acquired vealed "one and possibly a second aneurysm aris- stenosis (right).

327/47 JOURNAL A.O.A., VOL. 63, DEC. 1963 ing from the upper major subdivision of the right renal artery" (Fig. 6 ). The patient was subsequently taken to surgery where a 15 mm. aneurysm was resected. She tol- erated the procedure well and had an uncompli- cated postoperative recovery. The pathologic diagnosis was, "Aneurysm of the renal artery, congenital, and atherosclerosis of the renal artery." No abdominal murmur could be elicited following surgery.

Fig. 6. In Case I, a film taken with the translumbar aortogra- phic technique, showing one and possibly a second aneurysm arising from the upper major subdivision of the right renal artery. Splenic artery

Murmurs arising from the splenic artery are produced primarily by aneurysms. Increased tortuos- ity and atherosclerotic changes of this vessel are also important factors in the production of these murmurs. The importance of diagnosis of this con- Fig. 4. In Case I, an intravenous pyelogram showing a defect dition is evidenced by the frequently fatal out- on the superior margin of the right renal pelvis adjacent to the come of rupture of the aneurysm. The presence of right superior major calyx. a bruit may be the only finding elicited by an examiner which could create an awareness of the existence of the condition. Moore and Lewis" state that flägler m as early as 1920 made "the first pre- operative diagnosis on the basis of a systolic murmur over a pulsatile tumor mass. . . ." Spittel and associates" mention a case of rupture of a splenic artery aneurysm into the splenic vein with fistula formation and an associated abdominal bruit. Figure 7 illustrates the roentgeno- graphic finding on a scout abdominal x-ray film of a calcified, tortuous splenic artery with probable multiple aneurysms and diffuse dilatation of the entire vessel. The patient was a 68-year-old woman with a loud, high-pitched systolic bruit heard 1 inch above and to the left of the umbilicus. There was no transmission of the bruit below the umbilicus, which rules out the possibility of the murmur having arisen from the calcified lower abdominal aorta and iliac vessels.

Celiac and superior mesenteric arteries Fig. 5. In Case I. a retrograde pyelogrom, showing a partially calcified filling defect in the upper portion of the right renal Stenosis of the celiac and superior mesenteric pelvis. arteries may also produce audible epigastric bruits.

328/48 these vessels are notable for their lack of physical findings. As in splenic artery aneurysm, elicitation of an epigastric murmur by an astute examiner could lead to accurate diagnosis of the condition. Derrick, Pollard, and Moore 17 noted a systolic murmur limited to a small area just above and to the left of the umbilicus as the only pertinent physical finding in a case of narrowing of the superior mesenteric artery and the celiac axis. Webb and Hardy,18 writing on abdominal angina due to superior mesenteric artery obstruction, report that the only physical finding in such a case may be the presence of a bruit over the upper abdomen. Following is a case of stenosis of the celiac artery with the finding of an abdominal bruit.

Case 2 • This well-nourished, well-developed, 55- year-old white woman was admitted to the hospital with complaints of frequent episodes of abdominal "cramps and bloating." The onset of the complaints was approximately 2 years prior to Fig. 7. A scout abdominal x-ray film in a 68-year-old woman, showing a calcified, tortuous splenic artery with probable mul- admission. She stated that she would feel "full" tiple aneurysms and diffuse dilatation of the entire vessel. following the ingestion of very small amounts of food. Certain foods such as cabbage and fatty foods produced epigastric pain. No melena was present. She had had a hysterectomy 5 years prior to admission and lysis of abdominal adhesions 1 year following that time. The only pertinent physical findings were generalized mild abdominal pain on deep palpation, more severe in the upper left quadrant, and a grade 3 systolic murmur, harsh in character, heard 1 inch to the left and 2 to 3 inches above the umbilicus. Gastrointestinal and gallbladder x-ray series were reported as showing no gross organic disease. A lumbar aortogram was done with the patient under spinal anesthesia; this revealed "stenosis of the celiac axis, probably due to atheromatous plaque formation" (Fig. 8). The patient was taken to surgery and adequate circulation restored to the celiac artery via a by- pass. The abdominal murmur disappeared following the operation, and the patient is now free of her abdominal complaints. This case presents an excellent illustration of the importance that may be attached to the find- Fig. 8. In Case 2, a lumbar aortogram, revealing stenosis of ing of a bruit. When the lumbar aortography was the celiac axis. performed, the usual views were taken, but none showed definite arterial narrowing. However, in In a series of cases of stenosis of these vessels view of the loud unexplained epigastric murmur reported by Morris and associates, 16 an epigastric that was present, unusual oblique views were murmur was the usual finding. In many of their taken and the stenosis ultimately was seen. cases, obstruction of the two vessels occurred in the same patient. However, they describe one case Summary of stenosis of the proximal segment of the superior mesenteric artery without narrowing of the celiac Abdominal bruits may arise from defects of the artery, producing an upper abdominal murmur. splenic, celiac, superior mesenteric, and renal ar- The chronic syndromes produced by stenosis of teries. These bruits are most often elicited in the

329/49 JOURNAL A.O.A., VOL. 63, DEC. 1963 4. Goldblatt, H.: Renal origin of hypertension. Charles C Thomas, epigastrium and are usually continuous or systolic Springfield, 1948. in time. The importance of auscultating the ab- 5. Moser, R. J., Jr., and Caldwell, J. R.: Abdominal murmurs, aid in diagnosis of renal artery disease in hypertension. Ann. Int. Med. domen for the presence of these murmurs in all 56:471-483, March 1982. physical examinations is stressed. References to the 6. Gilliland, P. F., Deller, J. J., Jr., and Hall, R.: Bruit due to renal-artery stenosis; value of auscultation in diagnosis of renal hyper- subject have been reviewed and exemplary cases tension. New England J. Med. 264:659-880, March 30, 1981. presented. It has been found advantageous to aus- 7. Verstraete, M., et al.: Abdominal bruit in renal hypertension. Lancet 2:492, Aug. 28, 1961. cultate for these murmurs with a DeLee-Hillis 8. Brown, J. J., et al.: Diagnosis and treatment of renal-artery head stethoscope. Frequently the only physical stenosis. Brit. M. J. 2:327-338, July 30, 1960. 9. Morris, G. C., Jr., and DeBakey, M. E.: Diagnosis of renal vas- finding which may draw the examiners attention to cular disease. Am. J. Cardiol. 9:756-759, May 1982. 10. Smith, G. I., and Erickson, V.: Intrarenal aneurysm of renal an abdominal arterial defect is the presence of an artery; case report. J. Urol. 77:814-817, June 1957. epigastric murmur. 11. Coppinger, W. R., David, F., and Green, T. C.: Hypertension due to stenosis of renal artery. Rocky Mountain M. J. 58:37-41, April 1961. 12. Morris, G. C., et al.: Surgical treatment of hypertension re- Appreciation is expressed to Drs. Donald Smith sulting from renal artery stenosis. Am. Surgeon 26:745-749, Nov. and Floyd Smith for the use of the first case; to 1960. 13. Moore, S. W., and Lewis, R. J.: Splenic artery aneurysm. Ann. Drs. Neil Woodruff and John Fetzer for use of the Surg. 153:1033-1046, June 1961. second case; and to Drs. Edward Kani and Ralph 14. Hagler, F.: Beitrag zur Klinik des Leber-und Milzarteriana- neurysmas; zugleich ein Beitrag zur systematischen Auskultation der Johnson for the preparation of the x-rays and draw- Bauchgefasse. Wien. Arch. f. inn. Med. 1:508-562, 1920. ings. 15. Spinel, J. A., Jr., et al.: Splenic-artery aneurysm. S. Clin. North America 41:1121-1126, Aug. 1961. 16. Morris, G. C., et al.: Revascularization of celiac and superior 1. Vaughan, R. T., and Thorek, P.: Abdominal auscultation. Am. mesenteric arteries. Arch. Surg. 84:95-107, Jan. 1962. J. Surg. 45:230-234, Aug. 1939. 17. Derrick, J. R., Pollard, H. S., and Moore, R. M.: Pattern of 2. Peart, W. S., and Rob, C.: Arterial auscultation. Lancet 2:219- arteriosclerotic narrowing of celiac and superior mesenteric arteries. 220, July 30, 1960. Ann. Surg. 149:684-689, May 1959. 3. Julian, 0. C.: Chronic occlusion of aorta and iliac arteries. 18. Webb, W. R., and Hardy, J. D.: Relief of abdominal angina Surg. Clin. North America 40:139-151, Feb. 1960. by vascular graft. Ann. Int. Med. 57:289-295, Aug. 1962.

Treatment of inoperable carcinoma with newer chemotherapeutic agents: Report of three cases

E. L. McGOVERN, D.O.,* and WARD E. PER- steroids, and testosterone in one case of bone metas- RIN, D.O., Chicago, Illinois tasis from breast carcinoma.

The treatment of inoperable and metastatic neo- Methotrexate plasms in patients in the younger age group is a Intra-arterial infusion has been most useful in treat- problem often encountered by the average physi- ment of carcinoma of the head and neck which has cian. This paper discusses the use of intra-arterial been localized within the distribution of the exter- infusions of methotrexate in two cases of inoperable nal carotid arteries or in patients with untreated retroperitoneal tumors and the use of vinblastine, carcinoma of the cervix still confined within the Dr. McGovern is a resident in the Department of Internal Medi- distribution of the hypogastric arteries. cine, and Dr. Perrin is chairman of the Department, at Chicago Oste- opathic Hospital. Dr. McGovern was the recipient of a 1982 Mead Regression of tumor mass and subjective im- Johnson Grant. provement have been transitory in a majority of. °Address, 9801 S. Dobson Ave. patients. However, response of patients with epi-

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