Superior mesenteric artery syndrome presenting as an anorexia nervosa-like illness

Superior Mesenteric Artery Syndrome in Anorexia Nervosa: A Case Report and a Systematic Revision of the Literature

BACKGROUND

Superior mesenteric artery syndrome (SMAS) is a rare condition caused by the compression of the duodenum, which may occur in the case of fast weight loss. Currently, the relationship between superior mesenteric artery syndrome and anorexia nervosa is still unclear. The aim of this study is to identify the precocious clinical signs and symptoms of SMAS in patients affected by anorexia nervosa so as not to delay the diagnosis.

METHODS

We present the clinical case of a young female patient with anorexia nervosa complicated by SMAS. We performed a literature review of SMAS in children affected by anorexia nervosa between 1962 and 2023, according to the PRISMA Extension Guide for Scoping Reviews.

RESULTS

Reviewing the literature, 11 clinical cases were described for the pediatric age. The median age at diagnosis was 17 years (ranging from 13 to 18 years). The diagnosis of SMAS may be challenging as symptoms overlap those of anorexia, but it should be kept in mind mostly in cases of post-prandial abdominal pain, anxiety or depression, nausea, vomiting, and weight loss.

CONCLUSION

Even specific clinical symptoms may act as flag tags to drive attention to this rare but potentially fatal condition.

Wilkie’s syndrome as a cause of anxiety-depressive disorder: A case report and review of literature

BACKGROUND

Superior mesenteric artery syndrome is a disease with a complex diagnosis, and it is associated with complications that make it even harder to identify. Currently, a frequent association with psychiatric disorders has been noted. Despite numerous case reports and case series, the variability of the disease has not allowed the development of protocols regarding diagnosis and management.

CASE SUMMARY

A 33-year-old woman presented with abdominal pain, nausea, and bile vomiting over the last 15 mo, associated with a 15-kg weight loss over the last three months. After the onset of the symptoms, the patient was diagnosed with anxiety-depressive disorder and treated appropriately. Standard examinations excluded an organic cause, and the cause of the symptoms was considered psychogenic. The persistence of symptoms, even under treatment, prompted a computer tomography angiography examination of the abdomen and pelvis. The examination identified emergence at a sharp angle of 13.7° of the superior mesenteric artery, with a reduced distance between the artery and the anterior wall of the aorta up to a maximum of 8 mm. A diagnosis of aortomesenteric clamp was established. Surgical treatment by laparoscopic duodenojejunostomy was performed. Postoperative evolution was marked by a patent anastomosis at 1 mo, with a 10-kg weight gain and improvement of the associated anxiety.

CONCLUSION

This case report underlines two major aspects. One aspect refers to the predisposition of patients with superior mesenteric artery syndrome to develop psychiatric disorders, with an excellent outcome when proper treatment is administered. The second aspect underlines the key role of a multidisciplinary approach and follow-up.

Increase body weight to treat superior mesenteric artery syndrome

INTRODUCTION

Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction resulting from vascular compression of the third part of the duodenum in the angle between the abdominal aorta and SMA.

CASE PRESENTATION

A 19-year-old woman with anorexia nervosa with upper gastrointestinal obstruction symptoms resorted to the emergency department. A diagnosis of SMA syndrome was made. Symptoms were solved with conservative treatment aimed at increase body weight.

DISCUSSION

SMA syndrome is most commonly associated with debilitating illnesses. Patients present with acute or insidious upper gastrointestinal obstruction symptoms. Aortomesenteric artery angle of ≤25° is the most sensitive measure of diagnosis. Advances in both enteral and parenteral nutrition led to a shift towards conservative treatment.

CONCLUSIONS

Low threshold of suspicion is important to make a timely diagnosis and treatment. A conservative treatment aimed at increasing body weight is the first-line approach, leaving surgical intervention for failure cases.

Gastrointestinal symptoms and disorders in patients with eating disorders

The two most clinically serious eating disorders are anorexia nervosa and bulimia nervosa. A drive for thinness and fear of fatness lead patients with anorexia nervosa either to restrict their food intake or binge-eat then purge (through self-induced vomiting and/or laxative abuse) to reduce their body weight to much less than the normal range. A drive for thinness leads patients with bulimia nervosa to binge-eat then purge but fail to reduce their body weight. Patients with eating disorders present with various gastrointestinal disturbances such as postprandial fullness, abdominal distention, abdominal pain, gastric distension, and early satiety, with altered esophageal motility sometimes seen in patients with anorexia nervosa. Other common conditions noted in patients with eating disorders are postprandial distress syndrome, superior mesenteric artery syndrome, irritable bowel syndrome, and functional constipation. Binge eating may cause acute gastric dilatation and gastric perforation, while self-induced vomiting can lead to dental caries, salivary gland enlargement, gastroesophageal reflux disease, and electrolyte imbalance. Laxative abuse can cause dehydration and electrolyte imbalance. Vomiting and/or laxative abuse can cause hypokalemia, which carries a risk of fatal arrhythmia. Careful assessment and intensive treatment of patients with eating disorders is needed because gastrointestinal symptoms/disorders can progress to a critical condition.

Ultrasound imaging in diagnosis of superior mesenteric artery syndrome

OBJECTIVES

We screened a cohort of subjects affected by various degree of dyspepsia to reveal if they presented a reduction of the aorto-mesenteric angle and to diagnose suspected cases of superior mesenteric artery (SMA) syndrome.

DESIGN

Controlled, prospective, study.

SETTING

Subjects were studied as outpatients.

SUBJECTS

The study investigated a total of 3622 subjects referred to our department by their general practitioners for dyspepsia and/or abdominal pain. Interventions. Abdominal ultrasonography with power colour Doppler, gastroduodenoscopy, hypotonic duodenography, contrast-enhanced spiral computerized tomography were performed. MAIN OUTCOME MEASUREMENT AND RESULTS: Color Doppler revealed a significant reduction of the SMA angle in 29 of 950 subjects; gastroscopy showed duodenal compressive pulsation in 14 of 29 patients and X-ray revealed compression of the third segment of the duodenum in 28 of 29 patients. CT confirmed the presence of a reduced angle and various degrees of duodenal compression in all patients. Ultrasonography and CT examinations gave overlapping results (P > 0.05) in diagnosing pathological aorto-mesenteric angle.

CONCLUSION

The authors believe that the incidence of reduced aorto-mesenteric angle and SMA syndrome might be underrated. Ultrasound power colour Doppler imaging is useful in epidemiological screening of reduced aorto-mesenteric angle to diagnose suspected cases of SMA syndrome.

A pediatric AIDS patient with superior mesenteric artery syndrome

Superior mesenteric artery (SMA) syndrome is a unique type of small bowel obstruction resulting from the compression of the duodenum by the SMA. This is a case of SMA syndrome in a cachectic 6-year-old boy with AIDS who presented after a 2.3-kg weight loss in the preceding month. Unfamiliarity with this condition coupled with its intermittent, nonspecific symptomatology probably results in underdiagnosis of SMA syndrome. The presentation, predisposing and associated factors, and methods of diagnosis and treatment of SMA syndrome are all discussed.

[Acute gastric dilatation with superior mesenteric artery syndrome in a young girl with anorexia nervosa]

BACKGROUND

Acute gastric dilatation is a rare complication of anorexia nervosa which may be fatal in case of gastric perforation. Superior mesenteric artery syndrome may be associated with gastric dilatation.

CASE REPORT

A 14 year-old girl was admitted suffering from severe anorexia nervosa. Shortly after admission, she complained of abdominal pain related to a bulimic episode a few days before, followed by nausea and vomiting. Distended abdomen and tachycardia suggested acute small-bowel obstruction. A diagnosis of acute gastric dilatation with superior mesenteric artery syndrome was suspected on X-ray examination and confirmed by esophagogastrography after gastric evacuation. The patient improved rapidly under total parenteral nutrition. Upper gastrointestinal study repeated 10 days later showed normal stomach.

CONCLUSIONS

Small-bowel obstruction in anorexia nervosa first evokes acute gastric dilatation, and a perforation has to be ruled out by esophagogastrography. Association with superior mesenteric artery syndrome is possible; it does not necessarily lead to surgery.

Reversal of megaduodenum and duodenal dysmotility associated with improvement in nutritional status in primary anorexia nervosa

Anorexia nervosa is considered one type of eating disorder that may result in severe malnutrition. Patients with this disorder commonly complain of postprandial nausea, abdominal pain, and distension. We describe the radiologic and motility abnormalities associated with anorexia nervosa in a 21-year-old female. Barium gastrointestinal series demonstrated marked dilation of the duodenum, with prolongation of intestinal transit. A 4-hr fasting gastroduodenal motility study showed no propagating migrating motor complexes (MMC). Prolonged, but nonpropagating, bursts of high-amplitude phasic and tonic contractions were seen in the duodenum. In contrast, antral contractions were of low amplitude and esophageal motor function was normal. Metoclopramide and edrophonium caused an increase in gastroduodenal motor activity, but increased contractions were not associated with symptoms. Following a renutrition program that raised the patient's weight from 64 to 80% of her ideal body weight, the radiographic abnormalities and gastrointestinal dysmotility resolved completely. These observations suggest that anorexia-associated gastrointestinal motor dysfunctions are a consequence, not the cause of the generalized protein-calorie malnutrition associated with anorexia nervosa. The facts that motility in different parts of the gut is affected to different degrees and that gastric and duodenal muscle responds normally to exogenous stimulation argue against a generalized myogenic dysfunction and, rather, point to a reversible dysfunction of neural regulation.

Superior mesenteric artery syndrome: an unusual cause of intestinal obstruction in brain-injured children

Superior mesenteric artery syndrome is a rare cause of upper intestinal obstruction in both adults and children. Sixteen children with severe traumatic brain injury and spastic quadriparesis developed small intestinal obstruction while undergoing a rehabilitation programme between 1981 and 1990. Five patients met the roentgenographic diagnostic criteria. The presenting symptom was post-prandial bilious vomiting. The mean age was 13 (10-16) years. The mean time clapsed from injury to diagnosis was 53 days and from rehabilitation admission to diagnosis 22 days. The mean delay in diagnosis after onset of symptoms was 4 days. All patients were of disproportionately lower body weight in relation to height, with a mean weight loss of 7 kg. The mean percentile for weight was 18 and height 58, with a difference of 30 between height and weight percentiles. The patients were receiving nasogastric or gastrostomy tube feedings at the onset of the symptoms. All patients were treated non-surgically with gastric aspiration, nasojejunal or gastrojejunal feeding by passing a feeding tube distal to obstruction. No patient required intravenous hyperalimentation. There was no recurrence in any patient during the follow-up period of 1-5 years. Though rare, superior mesenteric artery syndrome can develop in brain-injured children with spastic quadriparesis, prolonged recumbency and recent weight loss. Increased awareness of occurrence of this condition and timely management will decrease morbidity and complications that may interfere with recovery.

Chronic superior mesenteric artery syndrome in anorexia nervosa

An 18-year-old woman presented with SMAS: an additional diagnosis of anorexia nervosa was later made. Both conditions should be considered when an adolescent presents with weight loss and vomiting.