Absent Doppler Flow Research Articles

Adnexal torsion: a review of diagnosis and management strategies.

Adnexal torsion remains a diagnostic challenge heavily reliant on high clinical suspicion, with patient presentation and imaging used as adjuncts to aid in its diagnosis. This review summarizes diagnostic and management techniques of adnexal torsion to assist providers when encountering this surgical emergency. Common findings of adnexal torsion include abdominal pain, nausea, vomiting, and adnexal mass or ovarian enlargement. An elevated neutrophil to lymphocyte ratio may be useful for diagnosis. A 'whirlpool' sign, 'follicular ring' sign, enlarged/edematous ovary, and absent Doppler flow to the ovary are highly suggestive of adnexal torsion. Intraoperative visual diagnosis of ovarian death is highly inaccurate, with only 18-20% of ovaries necrotic on pathological examination. Necrotic appearing ovaries have been shown to have follicular activity on ultrasound one year postoperatively. Pelvic ultrasound remains the first-line imaging modality. In patients of reproductive age, we recommend performing detorsion with ovarian conservation, even in cases where the tissue appears necrotic, given poor intraoperative diagnostic rates of tissue death. Retention of ovarian function is also reliant on a timely diagnosis and intervention. We emphasize that the risk of ovarian damage/loss outweigh the risk of a diagnostic laparoscopy in patients of reproductive age.

Is color Doppler ultrasonography reliable in diagnosing adnexal torsion? A large cohort analysis

Introduction Color Doppler ultrasonography (CDU) is widely used to diagnose adnexal torsion (AT). However, its validity remains questionable due to its low sensitivity. Our study aimed to evaluate the accuracy of CDU for the preoperative diagnosis of AT. Material and methods The electronic medical records of patients who were taken to the operating room with the diagnosis of suspected AT were reviewed. Patients having surgically/pathologically-proven AT were compared with patients who were found to have a different pathology at the time of surgery. CDU validity was assessed using a 2 × 2 table and compared with a diagnostic model that consists of the Doppler findings, patient’s age, and previous surgical history. Results AT was diagnosed correctly in 74.6% of cases. Absent Doppler flow was seen in only 18.6% of cases. Although its specificity and positive predictive value were high, CDU had very low sensitivity and negative predictive value. The combined diagnostic model exceeded CDU alone in terms of diagnostic accuracy. Conclusions The use of CDU alone is not a reliable modality to exclude AT. Absent Doppler flow is a sign of ovarian necrosis. Clinical correlation between CDU findings and the patient’s symptoms makes the diagnosis of AT more timely and accurate.

Comparison of Clinical Characteristics and Sonographic Findings of Adnexal Torsion between Pregnancy Trimesters.

Study Objective To compare the clinical characteristics and sonographic findings of adnexal torsion between pregnancy trimesters. Design A retrospective cohort study between 2011 and 2020. Setting A tertiary, university affiliated medical center. Patients or Participants Overall, 122 pregnant women with 131 separate episodes of surgically proven adnexal torsion. Interventions Laparoscopy for confirmation and treatment of adnexal torsion. Measurements and Main Results We collected demographic and clinical characteristics as well as sonographic findings and laboratory results of all adnexal torsion episodes. We compared the three trimesters of pregnancy. Overall, 92 of the episodes occurred during 1st trimester, 29 and 10 occurred during 2nd and 3rd trimester, respectively. The majority of cases were right sided (61%). Pregnancy achieved following assisted reproductive technology (ART) was more common in the 1st trimester group (p 6 was more common in 1st and 3rd trimester, compared to 2nd trimester (p=0.02). Gastrointestinal symptoms were also more common among patients in the 1st trimester (p The mean diameter of affected adnexa was similar in all trimesters, while the non-affected adnexa was marginally significantly smaller in the 2nd and 3rd trimesters. In approximately one third of all cases ultrasound findings included at least one specific feature: edematous ovary, absent doppler flow or presence of whirlpool sign. Absent doppler flow was more common in the 2nd and 3rd trimester compared to the 1st trimester (p Duration from admission to surgery was significantly longer in the 2nd and 3rd trimesters (p=0.002). Conclusion We found differences in the clinical, sonographic and laboratory manifestations of adnexal torsion in each trimester of pregnancy. When assessing pregnant patients with suspected adnexal torsion, these differences may assist in ameliorating an accurate diagnosis.

Clinical characteristics of adnexal torsion in premenarchal patients.

To compare clinical characteristics of adnexal torsion in premenarchal patients as compared to postmenarchal ones. A retrospective 22-year cohort of all cases of surgically verified adnexal torsion in premenarchal and postmenarchal patients (excluding postmenopausal and pregnant patients). Data collected included symptoms, signs and imaging at presentation, surgical mode, and procedure and histology. 16 cases of adnexal torsion among premenarchal patients were compared to 302 cases among postmenarchal ones. Clinical presentation was similar, notable only for more nausea and vomiting among the premenarchal group. Ovarian cysts were more commonly demonstrated among postmenarchal patients (82.4 and 30.8%, p < 0.001), as opposed to a normal adnexal appearance on ultrasound, which was more common in premenarchal patients (69.3 vs. 17.2%, p < 0.001). Absent Doppler flow, when preformed, did not differ statistically between the groups. Laparoscopic detorsion only was more commonly performed in premenarchal patients (56.2 vs. 19.8%, p = 0.001), with a trend for detorsion and cystectomy/fenestration, which were more common in postmenarchal surgeries (25 vs. 50.6%, p = 0.06). Histology was similar among both groups, with no cases of malignancy in premenarchal patients. Adnexal torsion in premenarchal patients is rare, presents similarly to older patients, but involves a normal adnexa in 69% of cases, therefore requiring a high index of suspicion in any premenarchal patient with acute onset abdominal pain.

Identification of Splenic Infarction by Emergency Department Ultrasound

BackgroundSplenic rupture or infarction can occur secondary to acute infectious mononucleosis. Patients with abdominal pain and known or suspected infectious mononucleosis mandate evaluation for these complications, which can have significant morbidity or mortality. Case ReportAn 18-year old man presented to the emergency department (ED) with a 2-day history of left upper quadrant abdominal pain. He had been diagnosed with mononucleosis 4 days before his ED presentation. Physical examination was notable for focal left upper quadrant tenderness. The treating physician's principal diagnostic considerations were splenic rupture or infarction secondary to mononucleosis. Point-of-care ultrasound was performed by the emergency physician, demonstrating multiple hypoechoic areas in the splenic parenchyma with absent Doppler flow, consistent with multiple splenic infarcts. The patient was admitted for observation, managed conservatively, and had an uneventful course. ConclusionEmergency ultrasound of the spleen can allow rapid diagnosis of splenic infarction and exclusion of splenic rupture in a patient at risk for splenic pathology.

RISK FACTORS FOR INTRAOPERATIVE PORTAL VEIN THROMBOSIS IN PEDIATRIC LIVING DONOR LIVER TRANSPLANTATION

P542 Running title: Intraoperative portal vein thrombosis Pathologic changes of the recipient native portal venous system may cause thrombosis of the portal vein, especially in pediatric living donor liver transplantation (LDLT). This study assessed the utility of Doppler ultrasound for the detection of intraoperative portal vein occlusion and identification of predisposing risk factors in the recipients. 73 pediatric recipients who underwent LDLT at Chang Gung Memorial hospital, Taiwan from 1994 to 2002 were included. Pre-operative and intraoperative Doppler ultrasound (US) evaluation of the portal vein was performed. Age, body weight, native liver disease, type of graft, graft recipient weight ratio (GRWR), type of portal anastomosis, portal velocity, portal venous size and presence of portosystemic shunt were analyzed for statistical significance of predisposing risk factors. Eight episodes of intraoperative portal vein thrombosis, with typical findings of absent Doppler flow in portal vein and prominent hepatic artery with a resistant index lower than 0.5 (P<0.001), were detected during transplantation, which was then corrected by thrombectomy and re-anastomosis. Children age ≤ 1year old (P=0.025), weight ≤ 10 Kg (P=0.024), low portal flow ≤ 7cm/sec (P=0.021), portal venous size ≤ 4mm (P=0.001), and GRWR > 3 (P < 0.017) were all risk factors for intraoperative portal vein thrombosis. Doppler US is essential in the pre-operative evaluation, early detection and monitoring of outcome of the portal vein in liver transplant.

Risk factors for intraoperative portal vein thrombosis in pediatric living donor liver transplantation.

Pathologic changes of the recipient native portal venous system may cause thrombosis of the portal vein, especially in pediatric living donor liver transplantation (LDLT). This study assessed the utility of Doppler ultrasound (US) for the detection of intraoperative portal vein occlusion and identification of predisposing risk factors in the recipients. Seventy-three pediatric recipients who underwent LDLT at Chang Gung Memorial Hospital, Taiwan, from 1994 to 2002 were included. Preoperative and intraoperative Doppler US evaluation of the portal vein was performed. Age, body weight, native liver disease, type of graft, graft recipient weight ratio (GRWR), type of portal anastomosis, portal velocity, portal venous size and presence of portosystemic shunt were analyzed for statistical significance of predisposing risk factors. Eight episodes of intraoperative portal vein thrombosis, with typical findings of absent Doppler flow in portal vein and prominent hepatic artery with a resistant index lower than 0.5 (p < 0.001), were detected during transplantation, which was then corrected by thrombectomy and re-anastomosis. Children age < or =1 yr (p = 0.025), weight < or =10 kg (p = 0.024), low portal flow < or =7 cm/s (p = 0.021), portal venous size < or =4 mm (p = 0.001), and GRWR >3 (p < 0.017) were all risk factors for intraoperative portal vein thrombosis. Doppler US is essential in the preoperative evaluation, early detection and monitoring of outcome of the portal vein in liver transplant.

Persistent Doppler flow predicts lack of response to multiple courses of indomethacin in premature infants with recurrent patent ductus arteriosus.

Although indomethacin produces ductus arteriosus constriction in extremely premature newborns, a recurrent symptomatic patent ductus arteriosus (PDA) frequently develops after the initial course of indomethacin. Currently, there is little information available to determine the effectiveness of a second course of indomethacin in producing permanent ductus closure. The objective of this study was to determine the rate of permanent ductus closure after a second course of indomethacin for a recurrent, symptomatic PDA and to identify the factors associated with permanent ductus closure. We identified 32 infants (<28 weeks' gestational age) 1) whose ductus was considered to be clinically closed after an initial course of indomethacin and 2) who subsequently developed a symptomatic PDA and received a second course of indomethacin. Clinical variables were evaluated for their association with failure of the second course (defined as surgical ligation after the second course for recurrence of a hemodynamically significant PDA). Data were analyzed by chi(2) analysis, Fisher's exact test, and the Mann-Whitney rank sum test. After the second course of indomethacin, 56% (18 of 32) of the infants had persistent or recurrent PDA-related symptoms that were considered to be hemodynamically significant. The only significant predictor of failure of the second indomethacin course was the demonstration (by Doppler echocardiogram) of persistent ductus flow within 24 hours of completing the initial indomethacin course. All of the 9 newborns with persistent Doppler ductus flow after the initial indomethacin course failed the second course of indomethacin. In contrast, only 39% (9 of 23) of newborns with absent Doppler flow after the initial indomethacin course failed the second course of indomethacin. Newborns who are <28 weeks' gestational age and develop a recurrent, symptomatic PDA after completion of an initial indomethacin course rarely respond to multiple courses of indomethacin if there was persistent Doppler evidence of ductus flow after completion of the initial course. Additional indomethacin treatment is unlikely to produce permanent ductus closure.

Sonography before, during, and after TIPS

Before transjugular intrahepatic portosystemic shunts (TIPS), sonography is used to identify patients with unsuitable hepatic and portal venous anatomy and to plan the procedure for those with suitable anatomy. Specifically, sonography is used to assess the size and morphology of the liver parenchyma, to detect hepatic masses, cysts, or biliary ductal dilatation, and to evaluate the hepatic vasculature for patency and direction of flow. A survey of the abdomen also will show the amount of ascites and the location of the liver relative to external landmarks. During TIPS, sonography may be used to facilitate atraumatic entry into the internal jugular vein or to guide puncture of the portal vein. After TIPS, routine sonography is used to detect shunt dysfunction. We routinely image patients at 24 hours, 3 months, 6 months, and every 6 months thereafter. Three findings most suggestive of shunt malfunction that prompt further investigation by shunt venography are (1) absent Doppler flow within the shunt, (2) peak flow velocity in the midshunt of 50 cm/sec or less, (3) reversal of flow direction in the intrahepatic portal vein branches from hepatofugal to hepatopetal.

Peripheral arterial disease in relation to glycaemic level in an elderly Caucasian population: the Hoorn Study

We investigated the cross-sectional association between peripheral arterial disease and glycaemic level in an age, sex, and glucose tolerance stratified random sample from a 50-74-year-old Caucasian population. Subjects treated with oral hypoglycaemic agents or insulin were classified as having known diabetes mellitus (KDM) (n = 67). Using two oral glucose tolerance tests, and based on World Health Organisation criteria, all other participants were categorized as having a normal (NGT) (n = 288), an impaired (IGT) (n = 170), or a diabetic (NDM) (n = 106) glucose tolerance. Prevalence rates of ankle-brachial pressure index less than 0.90 were 7.0%, 9.5%, 15.1% and 20.9% in NGT, IGT, NDM and KDM subjects, respectively (chi-square test for linear trend: p < 0.01). Prevalence rates of any peripheral arterial disease (ankle-brachial pressure index < 0.90, at least one monophasic or absent Doppler flow curve or vascular surgery) were 18.1%, 22.4%, 29.2% and 41.8% in these categories (chi-square test for linear trend: p < 0.0001). The prevalence of any peripheral arterial disease was higher in KDM and NDM than in NGT (p < 0.03, p < 0.0001, respectively), whereas no statistically significant difference was demonstrated between IGT and NGT. The same applied when using the ankle-brachial pressure index criterion. Logistic regression analyses showed that any arterial disease was significantly associated with HbA1c, fasting and 2-h post-load plasma glucose after correction for cardiovascular risk factors (odds ratios and 95% confidence intervals 1.35; 1.10-1.65 per %, 1.20; 1.06-1.36 and 1.06; 1.01-1.12 per mmol/l, respectively), whereas it was not associated with fasting and 2-h post-load specific insulin. Ankle-brachial pressure indices were not associated with either plasma glucose parameters or insulin in univariate or multivariate analyses. In conclusion, parameters of glucose tolerance are independently associated with any peripheral arterial disease, whereas insulin is not.