A classic experimental study by Miller and Nelson showed that as little as 1mL of free air can be detected below the right hemidiaphragm on properly exposed upright chest radiographs. This central location is explained by the flow of bile from the periphery of the liver toward the porta hepatis. Plain radiograph. clear: left; Bowel dilatation is only visible when the bowel contains gas. CBD And Pain Management: Is This Supplement Right For You. Extraluminal air trapped between adjacent loops of bowel may also have a characteristic triangular appearance in patients with pneumoperitoneum ( Fig. In various series, colonic perforation has been reported in as many as 7% of all large bowel obstructions and 2% of obstructing colonic carcinomas. Interpreting An Abdominal X-Ray (KUB) - Stepwards However, computed tomography (CT) revealed segmental luminal dilatation of the pelvic ileal loops, 2 transition zones with the beak sign observed in the left-sided pelvic cavity, and reduced enhancement of bowel loops. Pass it rectally, which is increased with movements such as walking or lifting 2. Other signs of pneumoperitoneum on supine abdominal radiographs. Chest radiographs obtained with the patient in an upright position are ideal for demonstrating free air because the x-ray beam strikes the diaphragms tangentially at their highest point. Colonic volvulus may involve different segments of the colon, as discussed in the following sections. The first collection of gas encountered from the top of the radiograph is usually in the antrum and body of the stomach. Subjects. Has anybody has this? The use of ambiguous terms, such as ''nonobstructive gas pattern,'' which does not indicate whether the gas distribution is normal or abnormal, should be abandoned. The findings on abdominal radiographs are often nonspecific. This sign has been described as one of acute appendicitis, even though the pathophysiology of the disease would more likely result in an absence of appendiceal gas. The sigmoid colon occupies the inferior aspect of the abdomen and is often recognized by its characteristic shape and haustral folds. Acute appendicitis with partial small bowel obstruction. Excessive intestinal gas is typically not an indicator of a serious health condition, but it may be a symptom of either irritable bowel syndrome (IBS) or small intestinal bacterial overgrowth (SIBO). Abdominal radiographs are usually not helpful for patients with volvulus of the transverse colon and may erroneously suggest sigmoid volvulus. Signs of appendicitis on abdominal radiographs include the following: The presence of an appendicolith is the single most helpful sign of appendicitis on abdominal radiographs. Various causes of free air are listed in Table 12-1 . We found the definition to be dichotomous and asynchronous between radiologists and their referring physicians. In some cases, air and intestinal contents may enter the twisted segment of bowel, producing abdominal distention and pain. Toxic megacolon is traditionally associated with ulcerative colitis, but it can also occur in patients with granulomatous colitis, amebiasis, cholera, pseudomembranous colitis, cytomegalovirus colitis, and ischemic colitis. Probably gastroentrities (unlikely as I don't have any of those symptoms) or ileus'. 12-12 ). Other gas collections biliary, intramural, etc. Free air C. Small bowel obstruction D. Nonspecific bowel wall thickening Answer: D. Nonspecific bowel wall thickening. As the cecal diameter increases, the risk of perforation also increases. The amount of gastric distention depends not only on the degree of obstruction, but also on the duration of obstruction, position of the patient, and frequency of emesis. Persistence of the dilated loop on sequential radiographs over several days should increase concern for a closed loop obstruction. Bananagirl, how much GasX do you take? Within Normal Limits: A Surprising Abdominal Mass - LWW last month, i had an abdominal x-ray and there was a huge gas bubble in the middle of my gut. Larger amounts of free air may occasionally outline the falciform ligament ( Fig. The plain film criteria for a small bowel obstruction follows the rule of 3's: small bowel dilated to 3 cm, greater than 3 air-fluid levels, or a small bowel wall greater than 3 mm thick. He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. The classic radiographic appearance consists of a massively dilated loop of sigmoid colon that has an inverted U configuration and absent haustral folds and extends superiorly above the transverse colon into the left upper quadrant beneath the left hemidiaphragm (even elevating the diaphragm), with air-fluid levels in both the ascending and descending limbs of this loop. (D) Abnormal but nonspecific gas pattern. Small amounts of gas (arrows Closed loop obstructions usually involve the small bowel and are caused by adhesions, internal hernias, or volvulus. The 2008 NATSISS included questions from the K5 to provide a broad measure of people's social and emotional wellbeing. term "non-specific bowel gas pattern," and inclusion of patients who have under - gone recent surgery in whom the differ-entiation of ileus from SBO is difficult. A nonspecific bowel gas pattern is a radiologic finding and not a condition in itself, however, when patients present to a physician with certain symptoms, an abdominal X-ray may be ordered. Pros and Cons of Breath Testing for Small Intestinal Bacterial Eating disorders include a spectrum of disordered thinking patterns and behaviours around eating. The absence of rectal gas is also an important differentiating feature. display: inline; In contrast, linear gas collections tend to be more readily apparent and should always be considered an important finding on abdominal radiographs, regardless of their location ( Fig. The characteristic findings of cecal volvulus, which are present on abdominal radiographs in about 75% of patients, consist of a markedly dilated, gas-filled cecum containing a single air-fluid level in an ectopic location ( Fig. Pneumatosis intestinalis and portal venous air (pneumoportogram) can both be seen on radiographs and with ultrasound. In contrast, emphysematous gastritis is a rare fulminant variant of phlegmonous gastritis; hemolytic Streptococcus is the most commonly implicated organism. An echogenic liver is also commonly identified with diffuse hepatic steatosis during a liver ultrasound examination. Normal bowel gas pattern B. A pseudo-Riglers sign may also result from Mach bands, a phenomenon in which there is the perception of a line at the interface between two areas of differing density (e.g., gas and soft tissue). Intestinal gas is a natural contrast agent for the interpretation of abdominal radiographs. When the patient is in the supine position, the gastric antrum and body tend to distend with air. Mechanical obstruction may occur if the terminal ileum is compressed by the appendix or narrowed by adhesive bands. Radionuclide findings do not help with a specific diagnosis in bowel . CHEST:Atelectasis, Hilar adenopathy, Hilar enlargement on CXR, Honeycomb lung, Increased interstitial markings, Mediastinal widening on mobile CXR, Pulmonary fibrosis, Pseudoinfiltrates on CXR, Pulmonary opacities on CXR,ABDO:Gas on abdominal X-ray, Kidney mass,BRAIN:Intracranial calcification, Intracranial structures with contrast,Ventriculomegaly, OTHER: Pseudofracture on X-Ray. 1 doctor answer 1 doctor weighed in Dr. Edward Hirsch answered Infectious Disease 34 years experience Normal: That is radiologist jargon for having a normal appearing bowel on the x-ray. 12-2B ), or even a polypoid or annular carcinoma (see Fig. Ileus seems to be a fancy word for 'bowel obstruction'? } Small bowel obstruction is often difficult to diagnose on abdominal radiographs. It may be caused by some combination of edema, fluid, and abscess formation in the right lower quadrant. A dilated, air-filled stomach is usually recognized without difficulty because of its characteristic shape and location associated with inferior displacement of the transverse colon. The gas-filled small bowel tends to occupy the central portion of the abdomen and has a smaller caliber than the colon. Mechanical obstruction is the other main category of abnormal bowel gas pattern. Gastric ulcers and masses are also occasionally visible ( Fig. What Does A Nonspecific Bowel Gas Pattern Mean? The abdominal x-rays obtained during admission and 1 hour before her upper esophagogastroduodenoscopy (EGD) revealed a nonspecific bowel gas pattern (Figure 1A and B). Gastric emphysema is a relatively benign form of pneumatosis usually resulting from iatrogenic injury to the mucosa at endoscopy or increased intraluminal pressure in the stomach associated with gastric outlet obstruction. In the United States, sigmoid volvulus tends to occur in older men and residents of nursing homes and mental hospitals, in whom chronic constipation and obtundation from medication are predisposing factors for gaseous distention of the sigmoid colon and stretching of the sigmoid mesocolon. Gastric outlet obstruction may be manifested on abdominal radiographs by a dilated stomach containing air, fluid, and/or debris. In a recent study that included trainees (3rd-year residents) and junior, as well as senior faculty, the mean sensitivity, spec-ificity, and accuracy of supine and upright Perforations sometimes occur at the site of obstruction, but usually result from progressive ischemia in the dilated colon or cecum proximal to the obstruction. Abdominal radiographs may reveal marked colonic distention, which is typically confined to the cecum, ascending colon, and transverse colon. . The term bascule is derived from bascula, the Latin word for scale. The point at which the ascending colon is folded represents the fulcrum of the scale. Intestinal gas has three sourcesswallowed air, bacterial production, and diffusion from the blood. Gas may also be present in the remaining colon, particularly the rectum. This has been described as cecal pseudovolvulus. 12-1 ). Radiologists use the term nonspecific gas pattern to denote a gas pattern that is not quite normal but that does not fulfill the criteria of a more specific diagnosis such as small bowel obstruction. 12-15 ). 12-13 ). These cookies will be stored in your browser only with your consent. As with sigmoid volvulus, elongation of the transverse mesocolon and close approximation of the hepatic and splenic flexures may allow the transverse colon to twist on its mesenteric attachment. When a splenic flexure volvulus is suspected, a single-contrast barium enema may be performed for a more definitive diagnosis. It is used synonymously with the terms paralytic ileus and nonobstructive ileus. (Courtesy Laura R. Carucci, MD, Richmond, VA.), Air is seen collecting centrally in the biliary tree (, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Perfusion Computed Tomography and Magnetic Resonance Imaging in the Abdomen and Pelvis. A history of intermittent, crampy abdominal pain replaced by steady, unrelenting pain should suggest a closed loop obstruction with vascular compromise. 4720.0 - National Aboriginal and Torres Strait Islander Social Survey What Does a Nonspecific Bowel Gas Pattern Mean? Because retroperitoneal gas is bound by fascial planes, it tends to collect in a linear fashion along the margins of the kidneys and psoas muscles and along the medial undersurface of the diaphragms ( Fig. Ulcre Perfor-Bouch: A Case Report - Gastro Hep Advances Echogenic Liver: What Does It Mean? | Fatty Liver Disease Findings were thought to be caused by neutropenic enterocolitis. I'm in need of a little help. Created for people with ongoing healthcare needs but benefits everyone. However, cross-sectional imaging studies such as CT and ultrasound have significantly improved the preoperative diagnosis of appendicitis (see Chapter 56 ). But opting out of some of these cookies may have an effect on your browsing experience. Thus, a delayed diagnosis of toxic megacolon on abdominal radiographs may have disastrous consequences for these individuals. Of their patients, 20% had cecal perforation. 12-7 ), usually with the cecal apex in the left upper quadrant. Performance cookies are used to understand and analyze the key performance indexes of the website which helps in delivering a better user experience for the visitors. After treatment, all findings were shown to have resolved on 2-week follow-up CT. We also use third-party cookies that help us analyze and understand how you use this website. There are two kinds of mechanical obstruction. Gas escaping from duodenal perforations tends to be confined to the right anterior pararenal space. Bowel gas patterns may point to an underlying cause bowel gas patterns include: Anosmia, Ataxia, Blepharospasm, Bulbar and Pseudobulbar palsy, Central Pontine Myelinosis, Cerebellar Disease, Chorea, Cranial nerve lesions, Dementia, Dystonia, Exophthalmos, Eye trauma, Facial twitches, Fixed dilated pupil, Horner syndrome, Loss of vision, Meningism, Movement disorders, Optic disc abnormality, Parkinsonism, Peripheral neuropathy, Radiculopathy, Red eye, Retinal Haemorrhage, Seizures, Sudden severe headache, Tremor, Tunnel vision, Bronchial breath sounds, Bronchiectasis, High airway pressures, Massive haemoptysis, Sore throat, Tracheal displacement, Atrial Fibrillation, Bradycardia, Cardiac Failure, Chest Pain, Murmurs, Post-resuscitation syndrome, Pulseless Electrical Activity (PEA), Pulsus Paradoxus, Shock, Supraventricular tachycardia (SVT), Tachycardia, VT and VF, SVC Obstruction, Abdominal distension, Abdominal mass, Abdominal pain, Asterixis, Dysphagia, Hepatomegaly, Hepatosplenomegaly, Large bowel obstruction, Liver palpation abnormalities, Lower GI haemorrhage, Malabsorption, Medical causes of abdominal pain, Rectal mass, Small bowel obstruction, Upper GI Haemorrhage. The presence of free intraperitoneal air (also known as pneumoperitoneum) is an important radiographic observation that usually indicates bowel perforation in patients with an acute abdomen. A ruptured appendix rarely may lead to the development of a small amount of free intraperitoneal air. These patients have a persistent mesentery on the ascending colon and, because of its greater mobility, the ascending colon can twist on its mesentery, producing a volvulus. Gas that enters the retroperitoneal spaces (also known as pneumoretroperitoneum) can usually be distinguished from intraperitoneal gas. Funny thing I had a BM and the pain stopped for a bit. One of the most common causes is a surgically created biliary enteric fistula such as a choledochojejunostomy or cholecystojejunostomy (see Fig. Yes 4. He is a co-founder of theAustralia and New Zealand Clinician Educator Network(ANZCEN) and is the Lead for theANZCEN Clinician Educator Incubatorprogramme. The most common nonsurgical cause of a choledochoduodenal fistula is a penetrating duodenal ulcer, and the most common nonsurgical cause of a cholecystoduodenal fistula is a gallstone eroding into the duodenum. After 24 hours of intensive treatment, the patient expired. Functional cookies help to perform certain functionalities like sharing the content of the website on social media platforms, collect feedbacks, and other third-party features. Still other patients may have a pseudo-Riglers sign caused by faint residual oral contrast material (usually from recent abdominal CT) coating the luminal surface of the bowel, so the increased density of the wall creates the erroneous impression that gas is present on both sides of the wall. Absence of a changing bowel pattern over time is worrisome. post-sexual activity, spa bath, water ski-ing), Hepatodiaphragmantic interposition of the colon, Secondary to colonic distention (obstruction or ileus), Gallstone ileus (biliary-enteric fistula) [, Hepatic portal venous gas (bowel infarction), Hydrogen peroxide ingestion (or other gas forming substance). The term "nonspecific abdominal gas pattern" should be abandoned because it may signify a normal condition or a pathologic state. font-weight: normal; PDF Review of Small-Bowel Obstruction: The Diagnosis and - CBC ACID BASE:Acid base disorders, Resp. Gastrointestinal symptoms are a well known consequence of disordered eating seen in acute treatment settings, but . Sign up. The duodenum may be filled with fluid, so it is not readily visible on supine radiographs. The intersection between eating disorders and gastrointestinal I feel like the normal dose isn't working for this. Ileus seems to be a fancy word for 'bowel obstruction'? font: 14px Helvetica, Arial, sans-serif; Other patients may have a localized ileus (also known as a sentinel ileus) related to acute inflammatory conditions in adjacent areas of the abdomen, including the right lower quadrant in patients with appendicitis, left lower quadrant in patients with diverticulitis, right upper quadrant in patients with cholecystitis, and mid upper abdomen or left upper quadrant in patients with pancreatitis. The term adynamic ileus refers to dilated bowel in the absence of mechanical obstruction. He created the Critically Ill Airway course and teaches on numerous courses around the world. It is an area where the remaining waste material is stored as feces before being removed via defecation. My abdominal xray came back with 'nonspecific gas pattern predominantly large bowel gas. A cross-table lateral view of the abdomen with the patient in a supine position may demonstrate free air in those who are physically unable to roll onto their sides. Cystic fibrosis (a disorder of your genes that causes severe damage to the lungs and other organs) Ileus Symptoms You'll feel symptoms in your stomach area for 24 to 72 hours. Underlying causes of this life-threatening condition include ingestion of caustic substances, severe gastroenteritis, and gastroduodenal surgery that compromises the vascular supply of the stomach. Cecal volvulus may occur in a variety of settings, including colonoscopy, barium enema, obstructive lesions in the distal colon, and pregnancy. oh yeah! In fact, 70% of patients with toxic megacolon develop this complication during their first episode of colitis. Occasionally, however, gas may extend to the level of the sigmoid colon. Non obstructive bowel gas pattern | HealthTap Online Doctor Most patients with SBO are treated successfully with nasogastric tube decompression. I had a chest x-ray just today and they said i had a lot of gas in my stomach; expect to burp a lot. The most feared complication is perforation. In other patients, small amounts of gas trapped between the small bowel folds on upright or decubitus abdominal radiographs may be recognized by tiny bubbles of gas lined up along the nondependent surface of the bowel, also known as the string of pearls or string of beads sign (see Fig. The location of retroperitoneal gas may provide a clue to its site of origin. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. Postoperative adhesions, chronic constipation, and congenital or postsurgical absence of the normal peritoneal attachments of the splenic flexure may predispose patients to this uncommon condition. Abdominal radiographs are often performed as an initial imaging test in patients with abdominal pain and distension. He is also a Clinical Adjunct Associate Professor at Monash University. pneumomediastinum, bronchopleural fistula), Air via uterine tubes (e.g. Colonic obstruction resulting from colonic carcinoma. An adynamic ileus occurs as a response to focal inflammation and may be localized to the right lower quadrant (also known as a sentinel ileus). However, the dilated bowel can be in the midline or can even extend into the right upper quadrant ( Fig. In some patients with small bowel obstruction who swallow relatively little air, supine abdominal radiographs may be unrevealing, whereas upright or decubitus abdominal radiographs (i.e., horizontal beam views) will show multiple air-fluid levels within small bowel loops proximal to the site of obstruction. Not much gas now but I'm afraid to eat and create more! 12-5A ). LOW:Anaemia, Hypocalcaemia, hypochloraemia, Hypomagnesaemia. a Supine anteroposterior abdominal radiograph demonstrates a nonobstructive bowel gas pattern with no evidence of pneumatosis or pneumoperitoneum. Vascular compromise may lead to edema and thickening or effacement of the folds within this loop. 12-9 ). Perforation of the retroperitoneal portions of the intestines, such as the duodenum, ascending and descending colon, and rectum, usually accounts for this finding. Now, getting to the non specific bowel gas pattern. His one great achievement is being the father of three amazing children. The abdominal radiograph has also been called a KUB k idneys, u reters (which are not visible), and b ladder. Although some patients with suspected toxic megacolon have undergone barium enemas, most authors believe that such examinations are contraindicated because of the risk of perforation. Intestinal permeability was calculated using gas chromatography to measure urinary sugar concentration. CT. Bowel dilatation is much more clearly demonstrated on CT. Unless the gas has been introduced iatrogenically by vascular catheterization, endoscopic manipulation, or other iatrogenic causes, the source of the gas is almost invariably the intestine. The risk of vascular compromise in the twisted segment is more important than the mechanical effects of the volvulus. ischemic gut, necrotizing enterocolitis), Extension from the chest (e.g. Toxic megacolon develops in 5% to 10% of patients with ulcerative colitis, but in only 2% to 4% of patients with granulomatous colitis. Finally, when patients swallow little or no air, abdominal radiographs may reveal multiple tubular, sausage-shaped soft tissue densities representing fluid-filled loops of small bowel without any intraluminal gas in the small bowel or colon, producing a so-called gasless abdomen. A complete blood count, chemistry panel, and serum pregnancy testing were normal. Preference cookies are used to store user preferences to provide content that is customized and convenient for the users, like the language of the website or the location of the visitor. Upright or left lateral decubitus abdominal radiographs are based on the principle that air rises to the highest point in the peritoneal cavity. Unlike patients with true cecal volvulus, however, cecal pseudovolvulus is associated with diffuse colonic distention, so it is usually possible to differentiate these conditions on the basis of the radiographic findings. Current concepts in. Advertisement cookies are used to provide visitors with relevant ads and marketing campaigns. If, however, horizontal beam views cannot be obtained in patients who are too sick or debilitated to stand or lie on their side, the radiologist must be able to recognize indirect signs of free intraperitoneal air on supine abdominal radiographs. 12-11A ). Pneumobilia almost always results from some type of communication between the bile ducts and intestine. Review of Small-Bowel Obstruction: The Diagnosis and When to Worry Portal venous gas has even been described as a transient finding on Doppler ultrasound during the early postoperative period after liver transplantation. The concept of a cecal bascule was challenged by Johnson and colleagues, who believed that these patients have a focal adynamic ileus of the cecum. #mergeRow-gdpr { Splenic flexure volvulus is the least common type of colonic volvulus. Serial radiographs showing a change in cecal diameter at 12- to 24-hour intervals may be more helpful than a single radiograph showing a dilated cecum. 12-14 ). Cecal volvulus can occur only when the right colon is incompletely fused to the posterior parietal peritoneum, an embryologic variant present in 10% to 37% of adults. He is on the Board of Directors for theIntensive Care Foundationand is a First Part Examiner for theCollege of Intensive Care Medicine. A closed loop obstruction refers to a segment of bowel that is obstructed at two points. This entity also requires a persistent mesentery on the ascending colon. Difficulties with oxygenation ensued, with a progressively widening arterial-alveolar gradient. Plain radiographs again revealed a non-specific gas pattern. An upper endoscopy was also normal. Undefined cookies are those that are being analyzed and have not been classified into a category as yet. Mild localized ileus or sentinel loop, Small bowel obstruction; central, valvulae conniventes, pliable (bent finger), Large bowel obstruction peripheral, haustra, contains feces, Perforated peptic ulcer (usually duodenal), Gastric ulcer perforation (benign or malignant), Intestinal perforation (e.g. . Gas may also extend medially across the anterior aspect of the psoas muscle, sparing its lateral margin. If you're experiencing pelvic pain, your doctor may recommend home treatment with over-the-counter pain medications, such as ibuprofen (Advil, Motrin). The term flat plate of the abdomen is dated and refers to a time when glass plates were used to produce images. Other causes of gastric outlet obstruction include an infiltrating antral carcinoma and, less commonly, scarring from granulomatous disease, radiation, or previous caustic ingestion. The intestinal tract in adults usually contains less than 200mL of gas. Study with Quizlet and memorize flashcards containing terms like Small and Large Bowel General Complaints, General Diagnostics for Abd Complaints, Bowel Obstruction Complaints and more. Intraperitoneal air that traverses the foramen of Winslow may become trapped in the lesser sac. In the absence of a surgical history, an obstructing hernia should be suspected. Surgeons have long believed that false-negative laparotomies are acceptable in some patients with right lower quadrant pain because of the serious, potentially life-threatening complications of untreated acute appendicitis. If the ectopic gallstone is 2.5cm or larger in diameter, it may obstruct the small bowel, usually at or near the ileocecal valve, and produce a so-called gallstone ileus; this is actually a misnomer because these patients have mechanical small bowel obstruction caused by a gallstone impacted in the distal ileum. 12-5B ). background: #fff; Linear collections of gas may also be seen in the subhepatic space, although the latter finding must be differentiated from subhepatic fat. An upper endoscopy revealed no endoscopic abnormalities. When the small intestine becomes completely obstructed, accumulation of swallowed air and intestinal secretions causes proximal dilation of bowel. A low-pressure barium enema performed without inflation of a rectal balloon should demonstrate smooth, tapered narrowing, or beaking, at the rectosigmoid junction with associated obstruction. Inflammatory Bowel Diseases, Volume 29, Issue 3, March 2023, Pages 444-457, https . Conversely, cecal carcinomas and those in the ascending colon are less likely to cause obstruction because of the wider caliber of the bowel and more liquid character of the stool. Retroperitoneal air in a patient with retroperitoneal perforation after endoscopy. Colonic Epithelial Circadian Disruption Worsens Dextran Sulfate Sodium When fluoroscopic barium studies are performed in patients with suspected gastric outlet obstruction, the duodenum should be carefully examined if the stomach appears normal. Mortality rates as high as 33% have been reported in these individuals. IPAP - Radiology Exam 1 part Deuce Abdomen Flashcards - Quizlet If the ileocecal valve is incompetent, refluxed gas in the small bowel may erroneously suggest a small bowel obstruction. Haustral folds in the colon are normally 2 to 3mm in width and occur at intervals of 1cm, whereas the circular small bowel folds (also known as plicae circulares) are 1 to 2mm in width and occur at intervals of 1mm. 12-11C ) or extrahepatic segment of the ligamentum teres in the right upper quadrant, the lateral umbilical ligaments (inverted V sign) in the lower abdomen, and the urachus. Since its original description by Rigler in 1941, this sign has been recognized as an important finding of pneumoperitoneum, but a moderate amount of free air must be present in the abdomen. The incidence of sigmoid volvulus also appears to be higher in people living at higher altitudes in South America and Africa. Log in. The apposed inner walls of the sigmoid colon may occasionally form a dense white line that points toward the pelvis.