Acute superior mesenteric artery syndrome complicated by severe gastric, pancreatic and renal ischaemia

Superior mesenteric artery syndrome (SMAS) is a rare and potentially life-threatening cause of small bowel obstruction in which the superior mesenteric artery impinges on the third portion of the duodenum. SMAS is typically encountered in patients with low body fat and a history of rapid weight loss and is often diagnosed as a chronic or subacute condition. Here, we describe a case of a healthy adolescent boy without typical SMAS prodromal symptoms presenting with a severe, hyperacute proximal small bowel obstruction due to SMAS. Complications arising from massive gastric and duodenal distension, including gastric, pancreatic and renal ischaemia, necessitated emergent surgical intervention consisting of the duodenojejunostomy bypass with partial gastric resection. The patient recovered without significant lasting consequences.

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.

Dynamic ultrasonography for optimizing treatment position in superior mesenteric artery syndrome: Two case reports and review of literature

BACKGROUND

Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction by extrinsic compression between the SMA and the aorta (SMA-Ao). Although the left lateral recumbent position is considered effective in the treatment of SMA syndrome, individual variations in the optimal patient position have been noted. In this report, we present two elderly cases of SMA syndrome that exhibited rapid recovery due to ultrasonographic dynamic evaluation of the optimal position for each patient.

CASE SUMMARY

Case 1: A 90-year-old man with nausea and vomiting. Following diagnosis of SMA syndrome by computed tomography (CT), ultrasonography (US) revealed the SMA-Ao distance in the supine position (4 mm), which slightly improved in the lateral position (5.7-7.0 mm) without the passage of duodenal contents. However, in the sitting position, the SMA-Ao distance was increased to 15 mm accompanied by improved content passage. Additionally, US indicated enhanced passage upon abdominal massage on the right side. By day 2, the patient could eat comfortably with the optimal position and massage. Case 2: An 87-year-old woman with vomiting. After the diagnosis of SMA syndrome and aspiration pneumonia by CT, dynamic US confirmed the optimal position (SMA-Ao distance was improved to 7 mm in forward-bent position, whereas it remained at 5 mm in the supine position). By day 7 when her pneumonia recovered, she could eat with the optimal position.

CONCLUSION

The optimal position for SMA syndrome varies among individuals. Dynamic US appears to be a valuable tool in improving patient outcomes.

Superior mesenteric artery syndrome and disseminated tuberculosis: "Double troubleˮ

Superior Mesenteric Artery (SMA) Syndrome is a rare condition characterized by compression of the third part of the duodenum between the aorta and superior mesenteric artery due to decreased angle between these two vessels due to loss of intervening pad of fat. Tuberculosis is one of the causes, and its association with it is rare. However, SMA syndrome with significant gastrointestinal symptoms in TB poses a greater challenge in management, particularly in dissemination. Strong clinical suspicion, timely diagnosis and appropriate antituberculosis therapy are the keys to successful management.

Superior mesenteric artery syndrome: An often overlooked cause of abdominal pain!

Objectives:

To determine the prevalence of superior mesenteric artery (SMA) syndrome in patients presenting with abdominal pains, and to evaluate computed tomographic (CT) findings needed for its diagnosis.

Methods:

This retrospective record-based study was carried out at the radiology department, from January 2016 to January 2021. All young patients (aged under 25) who underwent CT scans for abdominal pains were reviewed. Post-surgery, tumor, and trauma cases were excluded. Imaging findings for SMA syndrome were recorded as ‘suggestive’ (reduced aortomesenteric angle and distance with proximal duodenal dilatation), ‘possible’ (reduced angle and distance without proximal duodenal dilatation) and ‘probable’ (reduction of either angle or distance). Two radiologists interpreted the findings and consensus reporting was made. Diagnoses were confirmed on clinical grounds (symptomatic improvement by specific treatment and exclusion of other diagnoses), or barium studies. Imaging findings were compared to final diagnoses. McNemar’s Chi-square test was used to determine association.

Results:

Out of 141 patients (mean age=10.8, standard deviation=4), 7 (4.9%) patients mostly females were having SMA syndromes based on ‘suggestive’ imaging criteria (p=0.0005), and one patient underwent surgery.

Conclusion:

Superior mesenteric artery syndrome is not an uncommon condition and should be considered in differential diagnosis of acute abdomen in young patients after excluding other diagnoses.

Coexisting nutcracker phenomenon and superior mesenteric artery syndrome in a patient with IgA nephropathy: A case report

RATIONALE

Nutcracker and superior mesenteric artery (SMA) syndrome share the same pathogenesis, but the simultaneous occurrence of both diseases is quite rare. A combination of the nutcracker syndrome and IgA nephropathy has previously been reported. Herein, we report what we believe is the first case of coexisting nutcracker and SMA syndrome in a patient with IgA nephropathy.

PATIENT CONCERNS

A 15-year-old Chinese boy who was diagnosed with IgA nephropathy at 8 years of age presented with gross hematuria, fatigue, anorexia, nausea, and recurrent abdominal distension for 1 week without any obvious evidence of preceding infection. Laboratory data showed macroscopic hematuria, heavy proteinuria, and relatively normal renal function. Doppler ultrasonography and upper gastrointestinal gastrografin study were performed, respectively. Since his renal function deteriorated after admission, repeated renal biopsy was performed.

DIAGNOSES

IgA nephropathy with nutcracker phenomenon and SMA syndrome.

INTERVENTION

Immunosuppressive therapy combined with conservative therapy for superior mesenteric artery syndrome.

OUTCOMES

One month later, his abdomen symptoms such as anorexia and abdominal distension eased a lot with body weight increase of about 3 kg. After 6 months of follow-up, his body weight increased to 57 kg, serum creatinine decreased to 63 μmol/L, and urine microscopy showed 75.5 RBC/high-power field with 0.3 g urine protein per day.

LESSONS

Although the association between vascular compression and IgA nephropathy (IgAN) has not been elucidated yet, combination of nutcracker syndrome and SMA syndrome should be considered in patients with IgAN. The combination may increase the complexity of the disease, and renal biopsy should not be hesitated for differential diagnosis.

Co-occurrence of compression syndromes: celiac axis stenosis, superior mesenteric artery and nutcracker syndrome

Moreno Márquez et al. report an association between arcuate ligament syndrome (ALS) and the "nutcracker" phenomenon (compression of the left renal vein). The case illustrates the association between several syndromes, which all involve compression of vascular or gastrointestinal structures: arcuate ligament syndrome, superior mesenteric artery syndrome (SMAS) or Wilkie's syndrome, the "nutcracker" syndrome and May-Thurner syndrome (compression of the left iliac vein).

Superior Mesenteric Artery Syndrome Complicated by Gastric Mucosal Necrosis Following Congenital Scoliosis Surgery: A Case Report

CASE

This is a report of severe superior mesenteric artery (SMA) syndrome in an 11-year-old girl with congenital scoliosis following posterior spinal fusion and segmental spinal instrumentation. This was complicated by gastric mucosal necrosis but resolved satisfactory with prolonged nasogastric suction, intravenous fluids, and total parental nutrition.

CONCLUSIONS

All pediatric spine surgeons should be aware of SMA syndrome following spine surgery. This case demonstrates that although rare, significant complications such as gastric mucosal necrosis can occur. When present, it can be treated successfully with prolonged conservative management. Comanagement with pediatric gastroenterology and pediatric general surgery is recommended.

[Wilkie's syndrome as the cause of stomach pain in a young woman]

Wilkie's syndrome is a rare condition in which a decreased angle and distance between the superior mesenteric artery and aorta causes a compression of the third part of the duodenum, resulting ultimately in gastric dilation, gastric rupture and acute ischaemia of the bowel. The early symp-toms are those of duodenal obstruction. It is clinically char-acteristic, easily recognised on diagnostic imaging and is treated either conservatively or surgically. Although rare, Wilkie's syndrome is associated with severe morbidity, and should be considered in patients presenting with abdominal pain.

Co-occurring superior mesenteric artery syndrome and nutcracker syndrome requiring Roux-en-Y duodenojejunostomy and left renal vein transposition: a case report and review of the literature

BACKGROUND

The duodenum and the left renal vein occupy the vascular angle made by the superior mesenteric artery and the aorta. When the angle becomes too acute, compression of either structure can occur. Each type of compression is associated with specific clinical symptoms that constitute a rare disorder. If clinical symptoms are mild, conservative treatment is implemented. However, surgery is often the only solution that can improve quality of life and/or avoid life-threatening complications. This report describes a case of a patient with both types of aortomesenteric compression that required two separate surgeries to alleviate all symptoms.

CASE PRESENTATION

A 20-year-old white woman presented to the Emergency Room complaining of sudden onset severe left flank and lower left quadrant abdominal pain, nausea, and vomiting. A clinical work-up revealed elevated white blood cells and hematuria. She was discharged with a diagnosis of urinary tract infection. Symptoms continued to worsen over the subsequent 2 months. Repeated and extensive clinical work-ups failed to suggest evidence of serious pathology. Ultimately, an endoscopy revealed obstruction of her duodenum, and barium swallow identified compression by the superior mesenteric artery, leading to the diagnosis of superior mesenteric artery syndrome. She underwent a Roux-en-Y duodenojejunostomy. Six weeks later she continued to have severe left-sided pain and intermittent hematuria. Venography revealed compression of the left renal vein, extensive pelvic varices, and significant engorgement of her left ovarian vein. A diagnosis of nutcracker syndrome was made and a left renal vein transposition was performed. Significant improvement was seen after 8 weeks.

CONCLUSIONS

The disorders associated with aortomesenteric compression can lead to serious symptoms and sometimes death. Diagnosis is challenging not only because of the lack of awareness of these rare disorders, but also because they are associated with symptoms that are similar to those seen in less serious diseases. Guidance for health care professionals with respect to relevant radiological and clinical markers needs to be reconsidered in order to clarify the etiology of the diseases and create better diagnostic protocols.

Case report of gastric distension due to superior mesenteric artery syndrome mimicking hollow viscus perforation: Considerations in critical care ultrasound

RATIONALE

Critical care ultrasound identifies the signs of free intraperitoneal air and echogenic free fluid always indicates hollow viscus perforation (HVP) and needs immediate surgical interventions. However, in rare cases, these classic signs may also mislead proper clinical decisions. We report perforated viscus associated large peritoneal effusion with initial critical care ultrasound findings, whereas computed tomography (CT) examination confirmed a giant stomach due to superior mesenteric artery syndrome (SMAS).

PATIENT CONCERNS

A 70-year-old man was admitted to our emergency department with a complaint of recurrent vomiting with coffee ground emesis for 15 hours and worsen with hypotension for 6 hours. During gastric tube placement, the sudden cardiac arrest occurred. With 22 minutes resuscitation, sinus rhythm was restored.

DIAGNOSES

Quick ultrasound screen showed large echogenic fluid distributed in the whole abdomen. Diagnostic paracentesis collected "unclotted blood" and combined with a past history of duodenal ulcer, HVP was highly suspected. However, surgical intervention was not performed immediately as unstable vital signs and unfavorable coma states. After adequate resuscitation in intensive care unit, the patient was transferred to perform enhanced CT. Surprisingly, there was no evidence of HVP. Instead, CT showed a giant stomach possibly explained by SMAS.

INTERVENTIONS

Continuous gastric decompression was performed and 3100 mL coffee ground content was drainage within 24 hours of admission.

OUTCOMES

Abdominal distension was significantly relieved with improved vital signs. However, as the poor neurological outcome, family members abandon further treatment, and the patient died.

LESSONS

SMAS is a rare disorder, characterized by small bowel obstruction and severe gastric distension. Nasogastric tube insertion should be aware to protect airway against aspiration. Caution should be utilized to avoid over interpretation of ultrasonography findings on this condition.

Superior mesenteric artery syndrome: an uncommon cause of intestinal obstruction

Superior mesenteric artery syndrome, also Wilkie's syndrome, is an uncommon cause of upper intestinal obstruction. It includes compression of the third duodenal portion by the aorta and the overlying superior mesenteric artery when the angle formed by these two structures becomes smaller. It may result from significant weight loss or abdominal trauma, or may have a congenital origin. Treatment for most cases is conservative.

[Wilkies syndrome - a rare cause of duodenal obstruction in an adult female patient]

Wilkies syndrome or superior mesenteric artery syndrome is a rare cause of obstruction of the upper part of the gastrointestinal tract caused by compression of the third part of the duodenum between the abdominal aorta and the superior mesenteric artery at its origin. Partial or complete compression of the duodenum is caused by a decreased aortomesenteric angle. In this paper, the authors present the case report of a patient with chronic upper abdominal ileus. The clinical course of the illness, symptoms and surgical treatment of the patient are presented. The discussion section then focuses on diagnostic methods, characteristic clinical course and management of Wilkies syndrome.Key words: duodenal obstruction duodenojejunostomy superior mesenteric artery syndrome.

Superior Mesenteric Artery Syndrome Complicated by Diabetic Ketoacidosis and Graves' Disease in Slowly Progressive Insulin Dependent Diabetes Mellitus (SPIDDM): A Case Report and a Review of the Literature

A 48-year-old woman with a history of diabetes was admitted for nausea and vomiting with body weight loss. A blood examination revealed high plasma glucose and thyroid hormone levels and metabolic acidosis. She was therefore diagnosed with both diabetic ketoacidosis (DKA) and hyperthyroidism. Nausea and vomiting continued intermittently despite the administration of saline and insulin. The patient was further diagnosed with superior mesenteric artery syndrome (SMAS) after abdominal computed tomography revealed that a horizontal portion of the duodenum was sandwiched between the aorta and the superior mesenteric artery. Clinicians should be vigilant for SMAS in patients with both DKA and hyperthyroidism who present body weight loss.

Wilkie's syndrome An uncommon cause of small bowel obstruction in a young patient

Superior mesenteric artery (SMA) syndrome, also named as Wilkie's syndrome, is a rare, potentially life-threatening gastro- vascular disorder and an uncommon cause of proximal bowel obstruction characterized by a compression of the third and final portion of the duodenum by the abdominal aorta and the overlying superior mesenteric artery. There isn't a consensus regarding to the optimal treatment of this condition. We describe a case of Wilkie's syndrome in a young female with characteristic symptoms of upper intestinal obstruction, whose diagnosis was delayed for 2 years.

KEY WORDS

Superior mesenteric artery, Upper intestinal occlusion, Young female.

[Nutrition support treatment for refractory constipation patients complicated with superior mesenteric artery syndrome]

OBJECTIVE

To determine the incidence and risk factors associated to with refractory constipation patients complicated with superior mesenteric artery syndrome (SMAS), and to observe the role of nutritional support in its treatment.

METHODS

A prospective nested case-control study was conducted from a constipation cohort(n=973) to assess the incidence and risk factors of SMAS. Pitents with SMAS were matched to controls with a ratio of 1:4 by age and gender. Cases developed SMAS in long-term follow-up(n=26) and controls did not(n=104). Nutritional support was used in 26 patients with SMAS. The efficacy of nutritional support was evaluated by retrospective analysis.

RESULTS

The incidence of SMAS in this cohort of patients was 2.7%. Multivariate logistic analysis revealed BMI≤18 kg/m(2) (OR=2.89, 95%CI:1.14-7.31) and prolonged colon transit time(OR=3.57, 95%CI:1.36-9.35) were independent risk factors of SMAS in patients with refractory constipation. A total of 22 patients recovered after treatment of nutritional support. The successful rate of conservative treatment was 84.6%. The clinical symptoms, gastrointestinal quality of life index, Wexner constipation score and nutritional status were all significantly improved after treatment.

CONCLUSION

A BMI of less than 18 kg/m(2) and prolonged colon transit time are independent risk factors in refractory constipation patients complicated with SMAS. Nutrition support should be carried out according to illness condition and nutritional status, and combined with theatment of constipation simultaneously.

[Vomiting, abdominal pain and weight loss with an acquired anatomical cause: superior mesenteric artery syndrome]

Superior mesenteric artery syndrome (SMAS) is a rare and acquired anatomical condition characterized by vomiting, abdominal distension, weight loss and postprandial distress due to compression of the transverse portion of the duodenum between the superior mesenteric artery (SMA) and aorta, which causes duodenal outflow problems. We report a case series of three patients with SMAS. Diagnosis of the syndrome was made by augmenting a high degree of suspicion with repeat gastroscopies, CT scans and hypotonic duodenal contrast series showing compression of the horizontal part of the duodenum located between the vessels specified above. Medical therapy for the condition is aimed at nutritional rehabilitation so that weight gain results in relief of the obstruction. In each of our patients, surgical treatment was necessary during which the ligament of Treitz was divided and a side-to-side duodenojejunostomy was performed. In all, the weight loss seen preoperatively has been corrected.

Sonographic findings of superior mesenteric artery syndrome causing massive gastric dilatation in a young healthy girl

Acute gastric dilatation due to superior mesenteric artery syndrome in healthy individuals is extremely rare. A 17-year-old girl who complained of epigastric pain for two days following excessive eating was admitted to our hospital. She was nauseated but was unable to vomit. Succussion splash was positive. Bedside ultrasonography revealed a hyperactive duodenum, a distended stomach compressing on the inferior vena cava and a narrowed angle between the superior mesenteric artery (SMA) and the aorta. Abdominal computed tomography imaging confirmed the above findings. The angle between the aorta and SMA was only eight degrees. Gastrograffin follow-through showed complete obstruction of the third part of the duodenum. 3,500 ml of fluid was immediately drained through the nasogastric tube. Another gastrograffin study conducted five days later showed normal results. Bedside ultrasonography thus proved to be useful for both the diagnosis and management of superior mesenteric artery syndrome.

[Ultrasound in diagnosis of superior mesenteric artery syndrome]

OBJECTIVE

To reveal a possible reduction of the aorto-mesenteric angle and to diagnose suspected cases of superior mesenteric artery (SMA) syndrome. It was controlled, prospective study in which, in order to reveal a possible reduction of aorto-mesenteric angle, the following techniques.

MATERIALS AND METHODS

In a cohort of patients referred to our department by their general practitioners for unexplained dyspepsia and/or abdominal pain an abdominal ultrasonography with power colour Doppler was performed; patients with reduced SMA angle were screened by gastroduodenoscopy, hypotonic duodenography, contrast-enhanced spiral computerized tomography.

RESULTS

In a cohort of 1468 patients, 460 subjects were taken into consideration, specifi cally the patients where US and power colour Doppler had been adequately performed. US detected a signifi cant reduction of the SMA angle in 20 of those patients; in these 20 subjects, gastroscopy showed duodenal compressive pulsation in 5 of the 20 patients under examination, and X-ray revealed a compression of the third segment of the duodenum in 18 of them. The following CT examination confi rmed the presence of a reduced angle and various degrees of duodenal compression in all patients. US and CT examinations gave overlapping results (p>0.05) in diagnosing pathological aorta-mesenteric angle.

CONCLUSIONS

The analysis of data led the authors to believe that the incidence of reduced aorto-mesenteric angle and SMA syndrome might be underrated. US power colour Doppler imaging that is a rapid, repeatable, and non invasive, low cost and easy to perform diagnostic procedure, is useful in epidemiological screening of reduced aorto-mesenteric angle to diagnose suspected cases of SMA syndrome in patients with inexplicable abdominal pain.

Unusual complication of superior mesenteric artery syndrome: spontaneous upper gastrointestinal bleeding with hypovolemic shock

Superior mesenteric artery (SMA) syndrome is an unusual form of duodenal obstruction. Complications of SMA syndrome may sometimes develop and are usually associated with marked gastric dilatation, although most complications can be corrected by supportive treatment. In this article, we report a case of severe SMA syndrome with hypovolemic shock in a 24-year-old man. Multidetector-row computed tomography with reconstructed images was performed to establish the diagnosis. Spontaneous gastrointestinal bleeding is an extremely uncommon complication of SMA syndrome, and emergent surgical intervention was unavoidable in our patient. To our knowledge, no other such case has been reported in the English-language literature.

[Wilkie's syndrome]

Loss of retroperitoneal fatty tissue as a result of a variety of debilitating conditions and noxa is believed to be the etiologic factor of superior mesenteric artery syndrome. A case of a 35 years old female patient with severe malnutrition and weight loss is presented, who developed superior mesenteric artery syndrome. Various theories of etiology, clinical course and treatment options of this uncommon disease are discussed. In our case, conservative management was inefficient, while surgical treatment aiming to bypass the obstruction by an anastomosis between the jejunum and the proximal duodenum (duodenojejunostomy) was successful. An interdisciplinary teamwork provides the most beneficial diagnostic and therapeutic result in this often underestimated disease.

Gastric outlet obstruction

BACKGROUND/AIMS

To study causes of gastric outlet obstruction (GOO) in Saudi patients in a tertiary hospital. During one year (between March 2005 and April 2006), twelve patients were referred to the gastroenterology department as possible GOO.

METHODOLOGY

All patients had gastroscopy, barium meal and CT scan of abdomen. All patients presented with history of repeated vomiting usually after food. Two of these patients were known to have chronic duodenal ulceration. Gastroscopy in all patients showed food and fluid residue (in spite of fasting more than 12 hours), different lesions were found and biopsied. In patients who had pyloric obstruction, endoscopic dilatation for pyloric canal was done.

RESULTS

Four patients had neoplastic disorders (two with adenocarcinomas and one with neuroendocrine tumor and one had lymphoma) and they were referred for surgery. Three patients had chronic duo denal ulceration and two of them were managed by endoscopic pyloric dilatation and medical treatment. One patient had cytomegalovirus (CMV) gastritis together with vitamin B12 deficiency and he improved on medical treatment. One patient had eosinophilic gastroenteritis which improved with medical treatment. One patient had adult congenital pyloric stenosis and serial endoscopic dilatation failed and was referred for surgery. One patient had superior mesenteric artery syndrome and she improved with medical treatment and advises about food and postures and she did not require surgical intervention. Lastly, one patient had GOO secondary to pancreatic tumor and was managed surgically.

CONCLUSIONS

There are various causes of GOO as shown in our patients, some of which are rare and interesting such as CMV gastritis, adult congenital pyloric stenosis, eosinophilic gastritis and superior mesenteric artery syndrome. Those patients with rare causes will be included in discussion.

Superior mesenteric artery syndrome: an uncommon cause of upper intestinal obstruction

A previously healthy young boy who was operated for upper gastrointestinal obstruction, 12 weeks earlier, without relief of his symptoms of projectile bilious emesis and colicky pain, is described. He underwent upper gastrointestinal contrast studies, suggesting duodenal obstruction at its third part and superior mesenteric artery syndrome, which was confirmed by selective superior mesenteric arteriography. Duodenojejunostomy was carried out. The patient was symptom-free with normal built and growth after 4 years of follow-up.

Henoch-Schonlein purpura presenting duodenal involvement similar to superior mesenteric artery syndrome in a girl

Henoch-Schonlein purpura (HSP) is an inflammatory vasculitis involving the skin, joints, gastrointestinal (GI) tract, and kidneys. This is the first case report describing a 5-year-old girl with HSP presenting duodenal involvement which might be associated with superior mesenteric artery syndrome (SMAS).

Superior mesenteric artery syndrome in a basic military trainee

We present the case of a 19-year-old woman with feeding intolerance, due to superior mesenteric artery (SMA) syndrome, after weight loss experienced during basic military training. She had previous good health and presented with vomiting 8 weeks after starting military training. She had experienced a 16-pound (7 kg) weight loss during the course of training and was increasingly unable to tolerate meals, solids worse than liquids. Computed tomography of the abdomen with oral contrast revealed gastric and duodenal distention, with narrowing of the second portion of the duodenum at the SMA. A nasojejunal feeding tube was placed and she was given tube feedings. Weight increased and she eventually tolerated oral feedings. She completed military training and remains in good health. SMA syndrome is a rare cause of feeding intolerance, but can follow periods of acute weight loss, as is experienced by some basic military trainees.

Gastric pneumatosis and portal venous gas in superior mesenteric artery syndrome

Superior mesenteric artery (SMA) syndrome is a condition where compression of the duodenum between the root of the SMA and the aorta results in intermittent obstruction of the third part of duodenum. Portal venous gas associated with nonischemic bowel is uncommon. We report an 81-year-old man who developed gastric pneumatosis and hepatoportal venous gas due to SMA syndrome, which healed without any sequelae.

Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome

Superior mesenteric artery syndrome (Wilkie's syndrome) causes acute or chronic compression of the third part of the duodenum. Initially conservative treatment is tried, but on failure of treatment, duodenojejunostomy is the procedure of choice, usually done by open surgery. We present a case of superior mesenteric artery syndrome in which the duodenojejunostomy was done laparoscopically.

Superior mesenteric artery syndrome: an unusual case of intestinal obstruction

Superior mesenteric artery (SMA) syndrome is an uncommon cause of proximal intestinal obstruction, frequently occurring in patients who have had an important weight loss. The diagnosis can be difficult and usually is made by exclusion. The most characteristic symptoms are postprandial epigastric pain, fullness, voluminous vomiting and eructation. These symptoms are due to the compression of the third portion of the duodenum against the posterior structures by a narrow-angled SMA and surgical management is necessary. We report a case of SMA syndrome in a 23 year old patient, with a long history (since childhood) of voluminous vomiting, epigastric pain and an important weight loss. We performed small bowel enteroclysis, upper gastrointestinal series and endoscopy, biopsy of gastric and duodenal mucosa, abdominal computer tomography and ultrasonography to establish the diagnosis. Finally, the patient successfully underwent duodenojejunal anastomosis with a postoperative favourable outcome.

The acute surgical abdomen following Kyphoscoliosis corrective surgery

Superior mesenteric artery syndrome or cast syndrome is a recognised and reported complication of Kyphoscoliosis correction in orthopaedic surgery but much less published in the general surgical literature. The purpose of this case report is to review and highlight the occurrence, presentation and management of this unusual cause of the acute abdomen presenting as a general surgical emergency.

[Intermittent vomiting in a patient with superior mesenteric artery syndrome]

A 51-year-old woman presented with nausea, vomiting and weight loss. The diagnosis of superior mesenteric artery syndrome was established by CT and upper-gastrointestinal contrast radiography. This revealed a characteristic dilatation of the first and second parts of the duodenum and an abrupt cutoff in the third part due to vascular compression. The obstruction disappeared when the patient was placed in the left lateral recumbent position. The thin habitus of this patient probably played an important role in the development of the syndrome. She was given dietary and positioning advice and within 4 months relief of symptoms was accompanied by a weight gain of 4 kg.

Superior mesenteric artery syndrome: CT and ultrasonography findings

PURPOSE

The purpose of the study was to describe computed tomography (CT) and ultrasonography findings in superior mesenteric artery syndrome (SMAS).

MATERIALS AND METHODS

The study was performed on 89 CT examinations. Ultrasonography was performed on 32 and barium study was performed on four of these subjects. Group A consisted of cases with one or more of the following complaints: postprandial epigastric pain, weight loss and vomiting. Group B consisted of the remaining cases. Cases who had all of the above-mentioned clinical findings and duodenal dilatation, to-and-fro barium movement and SMA indentation in barium study were diagnosed as having SMAS. Body mass index (BMI, kg/m2) was calculated. The distance between SMA and aorta, at the location where the duodenum passes from, was measured on CT and ultrasonography. The angle between SMA and aorta was measured on ultrasonography images. Group and gender differences were analyzed with t-test, the relationship between clinical and CT findings was analyzed with Mann Whitney U test and the relations between BMI-CT and CT-ultrasonography measurements were analyzed with Pearson coefficients.

RESULTS

Of 13 cases in Group A, 3 were diagnosed as SMAS. Eight of the cases showed gastric and/or duodenal dilatation. In 6 cases, antrum had an abnormally high location at portal hilus. In Group A, the SMA-aorta distance was 6.6 +/- 1.5 mm and the SMA-aorta angle was 18.7 +/- 10.7 degrees . In Group B, these values were 16.0 +/- 5.6 mm and 50.9 +/- 25.4 degrees , respectively (p < 0.001). Cut-off values between SMAS and Group B were 8 mm (100% sensitivity and specificity), and 22 degrees (42.8% sensitivity, 100 % specificity). CT and ultrasonography measurements (p < 0.001) and SMA-aorta distance and BMI (p=0.004) were significantly correlated. The SMA-aorta distance was significantly shorter in females (p=0.036).

CONCLUSION

Gastric and/or duodenal dilatation and a diminished SMA-aorta distance have a significant correlation with clinical symptoms of SMAS that include postprandial pain, vomiting and weight loss.

The superior mesenteric artery syndrome; an unusual cause of vomiting

A 29-year-old female presented with anorexia, vomiting and weight loss. A diagnosis of superior mesenteric artery syndrome was made based upon contrast duodenography and then at laparotomy when the patient was successfully treated with a duodenojejunostomy. Superior mesenteric artery syndrome is a rare cause of vomiting not detectable by endoscopy, but is eminently amenable to treatment.

[Surgical treatment of ulcer disease in arterio-mesenterial compression of the duodenum]

Experience in surgical treatment of 124 patients with gastric and duodenal ulcers associated with chronic duodenal obstruction due to arterio-mesenterial compression of the duodenum is analyzed. This combination occurred in 12% of all patients with ulcers over 20-year period. Special methods of examination were used for diagnosis: probe duodenography with duodeno-manometry, hepato-bili-scintigraphy. Differential approach to choice of surgical method was developed, and two original methods of surgery are presented: selective proximal vagotomy and resection of the stomach in combination with duodeno-jejuno-anastomosis. Long-term results were studied in 75 patients, and in 93% of them they were assessed as excellent and good. Quality of life of patients after surgery depends on severity of chronic duodenal insufficiency.

Laparoscopic treatment of superior mesenteric artery syndrome

BACKGROUND

Superior mesenteric artery syndrome is caused by compression of the third portion of the duodenum by the superior mesenteric artery. Many disease states predispose one to this condition.

METHODS

We present a case report of a young female patient who presented with gastro-duodenal obstruction from superior mesenteric artery syndrome and subsequently underwent surgical treatment with minimally invasive techniques. Pathophysiology of SMA syndrome is reviewed.

RESULTS

The cause of superior mesenteric artery syndrome is variable but always results in duodenal obstruction. Surgery is one treatment option that is effective and can be performed laparoscopically.

CONCLUSION

Laparoscopic duodenojejunostomy is an acceptable method of treating superior mesenteric artery syndrome.

Superior mesenteric artery syndrome: diagnosis and treatment from the gastroenterologist's view

BACKGROUND

Superior mesenteric artery syndrome (SMAS) is caused by compression of the third part of the duodenum between the superior mesenteric artery and the aorta. It occurs most frequently in patients with rapid weight loss.

METHODS

We report two young patients, who each presented with a longstanding history of postprandial abdominal pain, nausea, and voluminous vomiting. The diagnosis of SMAS was established by digital fluoroscopy and contrast-enhanced spiral computed tomography (CT) scan. The findings obtained by endoscopic ultrasound (EUS) at the site of duodenal compression, using a miniprobe, were of substantial diagnostic value and in good agreement with the radiological observations.

RESULTS

Both patients, once diagnosed, were treated conservatively by providing enteral or parenteral high caloric nutrition. Weight gain was accompanied by the complete relief of symptoms.

CONCLUSIONS

Pathogenesis, diagnostic procedures, and therapy are reviewed in order to draw attention to this rare entity.