Auscultation of abdominal arterial murmurs C. ARTHUR MYERS, D.O.,° Flint, Michigan publications. Goldblatt's4 work on renal hyperten- sion 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 subse- quently 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 diag- nosis was, "Aneurysm of the renal artery, congenital, and atherosclerosis of the renal artery." No abdomi- nal 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 pro- duced 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 mur- mur over a pulsatile tumor mass. ." Spittel and associates" mention a case of rup- ture of a splenic artery aneurysm into the splenic vein with fistula formation and an associated ab- dominal bruit. Figure 7 illustrates the roentgeno- graphic finding on a scout abdominal x-ray film of a calcified, tortuous splenic artery with prob- able 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 ab- dominal 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 phys- ical 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 su- perior 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 ar- tery with the finding of an abdominal bruit. Case 2 • This well-nourished, well-developed, 55- year-old white woman was admitted to the hos- pital with complaints of frequent episodes of ab- dominal "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 physi- cal 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.