What is the treatment of the patient with the domino pain? What is the anatomy of the three first anterior arteries of the descending aorta

Question

USMLE step 2/3 question with step one anatomy component.

70 year old white male presents with severe abdominal pain after eating to the point that he is scared to eat in his lost weight. He has a past medical history of diabetes and hypertension.

1. what is the diagnosis and treatment?
2. . what is the relevant vascular anatomy; what are the first three anterior branches of the abdominal let your order, and their branches?

Answer 1

USMLE step 2/3 question with step one anatomy component.

70 year old white male presents with severe abdominal pain after eating to the point that he is scared to eat in his lost weight. He has a past medical history of diabetes and hypertension.

1. what is the diagnosis and treatment?
2. . what is the relevant vascular anatomy; what are the first three anterior branches of the abdominal let your order, and their branches?

SMA Syndrome

Answer 2

Question 1: What is the most likely diagnosis?

Given the patient's history of food aversion, weight loss, and abdominal pain after eating, the most likely diagnosis is Chronic Mesenteric Ischemia. The easy way to think of the disorder is angina of the belly vessels, very similar to the angina of the heart. When the demand increases (Heart= Myocardial Oxygen Demand, Intestines = Abdominal gut supply to digest food (Mesenteric Arteries), and when we do have enough blood to supply said arterial distribution, the outcome is pain. This lady has multiple risk factors for atherosclerotic vascular disease (Diabetes and Hypertension), indicative of an arterial problem or predisposition for arterial disease.

Question 2: What is the diagnostic method of choice?

Screening for the disease can be done with a duplex ultrasound; this is cheaper and quicker than doing the next test for a definitive diagnosis.

CT scan and, to be more precise, CT angiography is an excellent choice for diagnosing vascular pathologies. This diagnostic method is supplemented with contrast to highlight the blood vessels to form a distinct picture of the affected stenotic mesenteric blood vessels and provides a definitive diagnosis.

As a student is essential to be aware that CKD (increased BUN/Cr, etc.) is generally a contraindication for using CT with contrast, so resorting to abdominal ultrasound or MRI angiography is the choice you want to consider.

Lastly, if the suspicion is high for the disease and the initial tests are unrevealing, it is possible to consider performing catheter-based angiography. However, this is more invasive.

Question 3: What is the treatment?

The treatment for most symptomatic vascular disease diseases (Acute Coronary Syndrome, Carotid Stenosis, refractory peripheral artery disease) is restoring blood flow to affected blood vessels. Revascularization should be offered to all patients with symptomatic CMI. Preferred procedures are angioplasty or stenting. Percutaneous mesenteric stenting is the most commonly used method of revascularization.

As a student, it is also important to remember that for exams, test writers typically want you to be able to answer questions related to long-term management and prevention. Arterial diseases, for example, CMI, ACS, and PAD, are associated with atherosclerosis which in a nutshell involves both platelets and foamy macrophages (macrophages that have eaten a bunch of cholesterol); as these plaque grow, they occlude blood vessels and lead to decrease blood flow to distal tissues. The preventative therapy of choice should manage these two parameters; platelets (antiplatelet drugs: Aspirin, Clopidogrel, etc.) and cholesterol (Atovostatin); these drugs are given to the majority, if not all, patients with ASCVD.

Question 4: Important Anatomy to know.

The descending aorta gives off three majority tributaries: Celiac Trunk (Splenic artery, Common Hepatic Artery, and Left Gastric artery), Superior Mesenteric Artery, and Inferior Mesenteric Artery. The celiac trunk supplies the foregut (esophagus -> Upper duodenum), SMA supplies the Mid-Gut (Distal dudeuome -> Proximal 2/3 of transverse colon), and IMA (Distal 1/3 of transverse colon -> Proximal rectum).

Important to know the SMA IS THE MOST COMMONLY AFFECTED IN CMI.

Answer 3

This is chronic mesenteric ischemia. Another word for this intestinal angina. This is due to chronic atherosclerotic narrowing of large vessels: celiac, SMA, IMA. At least two of three would have to be significantly stenosed due to overlap and supply. Diagnosis would be, apart from history, with Doppler, CTA, MRA, or angiography.

-treatment would be by easily stenting the affected artery this text just a few minutes.

branches of the descending aorta are: celiac artery/Trunk – branches-Left gastric, common hepatic, splenic, superior mesenteric artery – Northeast branch distal compared to the proximal branching off the celiac, they are right colic, middle colic, ileocolic. Inferior mesenteric artery – left colic, Sigmoid branches, superior rectal artery