A Calcified Artery of Drummond, Could It Be a Sentinel Sign of Further Complications?

doi:10.4236/ss.2012.39091

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Surgical Science, 2012, 3, 460-462

http://dx.doi.org/10.4236/ss.2012.39091 Published Online September 2012 (http://www.SciRP.org/journal/ss)

A Calcified Artery of Drummond, Could It Be a Sentinel

Sign of Further Complications?

Shahe Boghossian, Arpan K. Banerjee

Heart of England NHS Trust, Birmingham, UK

Email: [email protected]

Received March 24, 2012; revised April 30, 2012; accepted May 18, 2012

ABSTRACT

Objective: To und erstand the role of the artery of Drummo nd in the elderly population. The artery plays a crucial role

in the anastomosis between the inferior mesenteric artery and sup erior mesenteric artery. Its maintenance is particularly

important for the survivability of the bowel in events of stenosis of either one of the native arteries; SMA or IMA.

Method: A 94 year old lady presents with post-prandial abdominal pain and significant emaciation. The patient under-

goes clinical and radiological investigations to find out the cause of her ailments. Results: Abdominal X-ray revealed a

serpentine structure that was later defined as the artery of Drummond, CT scan revealed a calcified and enlarged artery

of Drummond in addition to an occluded origin of SMA and celiac artery as well as a severe stenosis origin of IMA.

Conclusion: The artery of Drummond was immensely hypertrophied and was supplying the entire bowel through the

native IMA; subsequent occlusion of the IMA was the main cause that caused the demise of the patient.

Keywords: Artery of Drummond; Mesenteric Ischemia; Refeeding Syndrome

1. Case Report

A 94 year old lady was admitted to Accident and Emer-

gency complaining of six week history of abdominal pain,

nausea and significant emaciation. She was alert with a

GCS of 15. Examination of the abdomen revealed two

well healed midline incisions. Palpation of the abdomen

revealed fullness on the left side of her abdomen as well

as a hard palpable tube like structure that rolled under-

neath the examiner’s fingers. Auscultation of her abdo-

men showed faint yet audible bowel sounds. Rectal ex-

amination showed an empty rectum. Chest X-ray showed

bibasal collapse but no obstruction of the bronchi and no

signs of any pulmonary malignancy.

On admission, her initial blood test showed the fol-

lowing: Na: 132, K: 4.2, Creatin ine: 82 mmo l/lit, Alb: 40,

Bilirubin: 16, Phosphate: 1.02, Hemoglobin: 14.4, Plate-

lets: 252, White cell count: 11.32. Her observation chart

was normal however the patient looked dehydrated and

hence the patient was put on a slow IV drip. The patient

looked generally emaciated and was put on IV rehydra-

tion, oral rehydration, as well as fortified oral protein

sachets. The patient was not able to tolerate the oral feed

and hence a provisional diagnosis of Refeeding Syn-

drome was put forward. Three days later, a random arte-

rial blood gas showed an elevation of serum lactate to 6.5

mmol/lit with a base excess of –3.0 mmol/lit, pCO2: 4.58

kPa, pO2: 12.0 kPa, pH: 7.4 and a CRP of 161. Her white

cell count was elevated at 19.38/ml. Unfortunately, the

patient expired a week later.

2. Findings

The abdominal and chest X-ray showed a calcified trans-

versely oriented tube like structure the crossed the full

spectrum of the abdomen (Figure 1). This was initially

thought to be a foreign body but later confirmed to be a

calcified vascular structure. Contrast enhanced Computer

Tomography confirmed the structure to be a calcified

artery of Drummond (Figure 2) with a stenosed origin of

the Celiac, Superior Mesenteric Artery (Figure 3) and

the Inferior Mesenteric Artery (Figure 4). The diagnosis

eventually confirmed mesenteric ischemia in the elderly.

3. Discussion

Chronic mesenteric ischemia is an indolent condition af-

fecting mainly the vascular supply to the small bowel. It

is mainly manifested by postprandial pain and subse-

quent weight loss. The most common artery involved is

the Superior Mesenter ic Artery (SMA) which supplies th e

duodenum, the jejunum, the ileum as well as the right

si de of the large bowel [1]. Occasionally, the coeliac art er y

may be involved as well, either as a solitary condition or

in association with widespread atherosclerosis of the A or ta .

Congenital conditions such as acute angulation of the S MA

with the Aorta or fibromuscular dysplasia have been

S. BOGHOSSIAN, A. K. BANERJEE 461

Figure 1. Showing a very calcified tubular structure that

was initially confused as a foreign body.

Figure 2. Showing a calcified tubular structure at the very

ventral edge of the patient’s abdomen.

sporadically reported [2]. Acquired yet non-occlusive

mesenteric ischemic (NOMI) conditions include athero-

sclerotic degeneration of the origin of the SMA, vascu-

litides affecting the SMA as well as other mesenteric

vessels, thrombosis of the left renal vein causing indirect

Figure 3. Shows no flow from the orifice of the SMA (red

pointer) and a calcified meandering structure on the sur-

face of the skin.

Figure 4. Shows no flow in the IMA (red pointer) and

already shows a miniscule amount of gas in the luminal

bowel (blue pointer).

obstruction to the origin of the SMA, paraaortic tumours

and lymphadenopathy, pancreatitis [3] and hypercoagu-

lable states [4,5]. In contrast, the most common cause of

acute mesenteric ischemia is mainly atrial fibrillation,

hypercoagulable states as well as septic emboli from the

cardiac valves or other sources in the body [6]. In the

elderly, as discussed earlier, background atherosclerotic

S. BOGHOSSIAN, A. K. BANERJEE

462

disease is a common finding on non-invasive imaging

studies, as demonstrated by the images shown under-

neath (CT and AXR). However, in an acute ischemic

event, the anastamotic feeder vessel would thrombose

rendering the bowel non-viable and causing irreversible

ischemic injury. This case highlights a variant whereby

the coeliac axis territory and the SMA territory are sup-

plied by a dominant artery of Drummond which in turn is

supplied by the IMA as demonstrated by abdominal im-

aging. The artery of Drummond is a crucial anastomosis

between the superior and inferior mesenteric artery. Ad-

ditionally the viability of this arc is crucial for the sur-

vivability of Endovascular Aortic Aneurysm repairs

whereby the origin of the inferior mesenteric artery is

iatrogenically occluded [7,8]. Our assessment of the pa-

tient’s condition certainly demonstrated th at she had long

standing atherosclerotic disease as described from her

weight loss, but we can certainly say that acute embolisa-

tion of the inferior mesenteric artery (IMA) was a key

factor in her rapid deterioration. The case highlights a

case of hypertrophy of the artery of Drummond that was

crucial in maintaining nutrient supply to the entire fore-

gut and hindgut through the IMA.

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