VIR GI

Question 1

Abdominopelvic compression syndromes: MALS

1. What is this.
2. When does this worsen?
3. Ex
4. Sx
5. Tx?
   
   1. Is angioplasty/stenting recommended?

Answer 1

1. Celiac trunk compression by the median arcuate ligament, part of the diaphragmatic crura.
2. W/expiration, as the crus elevates, so does the celiac trunk, then gets jammed superiorly.
3. Thin, young women.
   
   1. When there’s intra-abdo fat then the MAL is separated from the celiac trunk by fat.
4. Crampy abdo pain.
5. Surgical release of the MAL.
   
   1. No, not effective 2dry to device failure.

Question 2

Abdominopelvic compression syndromes: SMA syndrome

1. Aka
2. RFs
3. Path
4. Initial Tx
5. Surgical Tx

Answer 2

1. Wilkie syndrome
2. Path: fat & lymphatic tissues around the SMA buffer the duodenum against compression & in severe wt loss this cushion is diminished, decreasing angulation & distance b/w the Ao & SMA.
3. Any RFs for wt loss: anorexia; hypercatabolic states (burns, malignancy, major surgery); CHF causing cachexia.
4. Initial Tx: NG tube, nutritional correction incl enteric feeding w/tube past point of compression; posturing.
5. Surgical: duodenojejunostomy; lap surgery w/lysis of ligament of Treitz & duodenal mobilizaiton.

Question 3

Abdominopelvic compression syndromes: nutcracker syndrome

1. Defn
2. What this is similar to
3. Variant
4. Ex
5. Sx
6. Ix:
7. Tx

Answer 3

1. Compression of L renal vein by the Ao.
2. SMA syndrome, but it’s the L renal vein instead of the duodenum that’s being compressed.
3. Posterior nutcracker, i.e., retro-Ao L renal vein.
4. Slightly F>M
5. L flank or pelvic pain, hematuria, orthostatic proteinuria, pelvic congestion, varicocele.
   
   1. Hematuria path: venous HTN develops, resulting in rupture of veins into the collecting system.
6. Ix:
   
   1. Reduced Ao/SMA angle: normal ~45°.
   2. L renal vein stenosis:
      
      1. compression ratio = precompressed vein compressed vein; if >2.25, highly sens/spec.
   3. Collaterals: typically, L gonadal vein, which will show early enhancement during PV phase.
7. The majority resolve spontaneously.
   
   1. Angioplasty + stenting.

Question 4

Abdominopelvic compression syndromes: retroaortic L renal vein or circumAo renal collar, aka atypical nutcracker Sx

1. Diff b/w the two.
2. Prevalence?
3. Sx, etc.

Answer 4

1. RetroAo L renal vein (more common, 2%): one L renal vein that passes behind the Ao.
   
   1. CircumAo renal collar (less common): accessory L renal vein that passes posterior to the Ao, w/a normal L renal vein passing anterior to the Ao.
2. Everything else the same as conventional nutcracker Sx.

Question 5

Abdominopelvic compression syndromes: May-Thurner

1. Path
2. RFs
3. Sx
4. Tx

Answer 5

1. Venous thrombosis of L common iliac vein by R common iliac artery.
   
   1. Chronic compression causes fibrous adhesion in the vein, causing thrombosis.
2. Prolonged immobilization; pregnancy.
3. Sx: LLE edema/pain, varicose veins, DVT or venous ulcers. Think of this is there is a request for LLE US for DVT and it’s negative.
4. Tx: endovascular thrombolysis + stenting, only if pt has clot and/or is symptomatic.

Question 6

Distal aorta, iliac, pelvic & leg arteries: iliac atherosclerotic disease:

1.

Answer 6

1.

Question 7

Distal aorta, iliac, pelvic & leg arteries: iliac artery aneurysm:

1.

Answer 7

1.

Question 8

Distal aorta, iliac, pelvic & leg arteries: persistent sciatic artery:

1. Common?
2. Any gender predilection?
3. % bilateral?
4. What causes it?
5. What is it associated w/ and not?
6. Typical origin, & what specific part?
   
   1. Course & termination?
   2. Anatomically, on axial views, where will you see it?
7. What does it supply?
   
   1. Therefore, what is often seen with it?
8. Sequelae?
9. Pathognomonic sign?
10. Tx/Mgt & how?

Answer 8

1. Rare (up to 0.06%).
2. None!
3. 1/3
4. A persistent embryonic axial limb (sciatic) artery (which normally regresses at wk 12).
5. Associated w/venous anomalies, e.g., AVF and varicose veins, but not assoc w/other aneurysms.
6. Origin: internal iliac a., specifically the inferior gluteal (remember this as it lies deep to the gluteus m.).
   
   1. Through the greater sciatic foramen below the piriformis, down the thigh beside the sciatic nerve; termination: popliteal a (80%).
   2. In between the ischial tuberosity and gluteus maximus.
7. The majority of the lower extremity.
   
   1. Rudimentary superficial femoral and profunda femoris a.
8. Aneurysms (48%) & LE ischemia if there are emboli.
9. Cowie’s sign: diminished/absent femoral pulse + palpable popliteal pulse (present in a minority of cases).
10. Tx/Mgt: f/u required b/c of high incidence of aneurysm formation. US usually recommended.

Question 9

Distal aorta, iliac, pelvic & leg arteries: pelvic vascular trauma:

1.

Answer 9

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