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Aoyagi R, Ogasawara M. Abdominal Pain and Bilious Vomiting With a Dilated Duodenum and Stomach in a Five-Year-Old Boy. Gastroenterology 2024; 167:450-453. [PMID: 38355060 DOI: 10.1053/j.gastro.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Rui Aoyagi
- Department of Pediatrics, Showa General Hospital, Tokyo, Japan.
| | - Masashi Ogasawara
- Department of Pediatrics, Showa General Hospital, Tokyo, Japan; Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan
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2
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Jayakar S, Mogekar S. Superior Mesenteric Artery Syndrome: A Report of a Rare Case. Cureus 2024; 16:e63572. [PMID: 39087162 PMCID: PMC11290701 DOI: 10.7759/cureus.63572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 07/01/2024] [Indexed: 08/02/2024] Open
Abstract
Superior mesenteric artery (SMA) syndrome is a rare disease in which the third part of the duodenum between the SMA and the abdominal aorta is compressed, leading to small bowel obstruction. Treatment is usually conservative, such as parenteral and nasojejunal nutrition. The pathophysiology includes loss of the retroperitoneal fat layer and subsequent duodenal compression. We present a 53-year-old malnourished female patient who came with complaints of vomiting, constipation, abdominal pain, and distension for four days. This article highlights the diagnostic challenges associated with SMA syndrome and emphasizes the importance of early diagnosis and intervention.
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Affiliation(s)
- Sudhir Jayakar
- General Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr D. Y. Patil Vidyapeeth, Pune, IND
| | - Smitha Mogekar
- General Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr D. Y. Patil Vidyapeeth, Pune, IND
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Gharti SB, Shrestha N, Thapa KS, Shah R, Khanal P, Shah RK, Gharti SB, Tiwari U. Superior Mesenteric Artery Syndrome in an 11-Year-Old Boy: A Case Report. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2024; 17:11795476241257036. [PMID: 38800090 PMCID: PMC11119349 DOI: 10.1177/11795476241257036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 05/08/2024] [Indexed: 05/29/2024]
Abstract
Superior Mesenteric Artery Syndrome (SMAS) is a rare but potentially life-threatening condition caused by the compression of the duodenum by the superior mesenteric artery. We report a case of an 11-year-old male who complaint of abdominal pain and intermittent vomiting for last 3 weeks. Diagnosis of SMAS was made with the help of radiological findings. The patient was managed conservatively with nutritional support, prokinetic agents, and stomach decompression. After 2 weeks of treatment, the patient's symptoms improved, and he was discharged from the hospital.
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Affiliation(s)
| | | | | | - Rajat Shah
- Birat Medical College Teaching Hospital, Biratnagar, Nepal
| | - Priti Khanal
- Nobel Medical College Teaching Hospital, Biratnagar, Nepal
| | | | - Sanjeeb Babu Gharti
- Universal College of Medical Sciences and Teaching Hospital, Bhairahawa, Nepal
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4
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Moore ZJ, Eldredge RS, Russell KW. Acute superior mesenteric artery syndrome complicated by severe gastric, pancreatic and renal ischaemia. BMJ Case Rep 2024; 17:e259177. [PMID: 38383132 PMCID: PMC10882347 DOI: 10.1136/bcr-2023-259177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024] Open
Abstract
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.
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Affiliation(s)
| | - Richard Scott Eldredge
- Department of Surgery, The University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of General Surgery, Mayo Clinic Arizona, Scottsdale, Phoenix, Arizona, USA
| | - Katie W Russell
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
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5
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Caterine S, Patil NS, Takrouri H, Issenman RM, Stein NR, Donnellan J, Yikilmaz A. Understanding the diagnosis of superior mesenteric artery syndrome: analysis of the location of duodenal impression on upper gastrointestinal studies. Pediatr Radiol 2023; 53:2633-2641. [PMID: 37837457 PMCID: PMC10697883 DOI: 10.1007/s00247-023-05782-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Upper gastrointestinal (GI) contrast studies are frequently requested to aid superior mesenteric artery syndrome diagnosis, a rare entity. Compression of the third duodenal part is expected to be mid-to-left of the midline where the superior mesenteric artery arises from the aorta; however, a duodenal impression to the right of the midline due to normal anatomic impression by the inferior vena cava (IVC) is often encountered and frequently misdiagnosed. OBJECTIVE The purpose of this study was to determine the frequencies of (1) normal right-of-midline duodenal impressions and (2) mid-to-left of midline compressions in upper GI studies in a tertiary pediatric referral center. MATERIALS AND METHODS All upper GI studies performed at our institution over 2 years were retrospectively evaluated to determine whether the duodenum had vertical duodenal impression to the right of the vertebral midline, mid-to-left of the vertebral midline, or no identifiable duodenal impression at all. RESULTS In total, 538 upper GI studies were included in this analysis. A total of 275 male and 247 female patients between 0 and 17 years of age (median: 6 years, range: 1 month-17 years) were included. Of 538 total upper GI studies, there were 240 studies (44.6%) with a right-of-midline impression. There were only 10 studies (1.9%) with a mid-to-left of midline compression, and 9/10 also showed a concurrent right-sided impression sign. CONCLUSION Right-of-midline duodenal impression is a normal anatomic finding caused by the IVC and should not be confused with superior mesenteric artery syndrome. In the presence of an appropriate clinical context, proximal duodenal dilation, "to-and-fro" motion of contrast, and duodenal impression at mid-to-left of midline, a diagnosis of superior mesenteric artery syndrome should be considered.
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Affiliation(s)
- Scott Caterine
- Department of Pediatric Radiology, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Nikhil S Patil
- Michael G. Degroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Heba Takrouri
- Department of Pediatric Radiology, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Robert M Issenman
- Department of Pediatric Gastroenterology, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Nina R Stein
- Department of Pediatric Radiology, McMaster Children's Hospital, Hamilton, ON, Canada
| | - John Donnellan
- Department of Pediatric Radiology, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Ali Yikilmaz
- Department of Pediatric Radiology, McMaster Children's Hospital, Hamilton, ON, Canada.
- Diagnostic Imaging, Hamilton Health Sciences, McMaster Children's Hospital, Room 2S28, 1200 Main St. West, Hamilton, ON, L8N 3Z5, Canada.
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Danushka PGN, Jayasinghe R, Wijemanne A. Superior mesenteric artery syndrome treatment strategies: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231184587. [PMID: 37425139 PMCID: PMC10328168 DOI: 10.1177/2050313x231184587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/09/2023] [Indexed: 07/11/2023] Open
Abstract
Superior mesenteric artery syndrome is a rare manifestation of small bowel obstruction caused by the compressed third part of the duodenum between the superior mesenteric artery and the abdominal aorta. We present the case of an 18-year-old female and presented with symptoms of duodenal outflow obstruction. Upon investigation, her cross-sectional imaging revealed partial obstruction of the distal duodenum at the crossing of superior mesenteric artery forming an acute angle between the superior mesenteric artery and aorta. Failing initial attempts at conservative management, the patient underwent laparotomy and duodenojejunostomy with complete relief of symptoms. Superior mesenteric artery syndrome is a rare but a sinister diagnosis in patients presenting with features of duodenal outflow obstruction. Cross-sectional imaging plays an important role in diagnosis.
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Wasef K, Hudnall A, Schmidt CR, Marsh JW, Boone BA. Robotic modified Strong procedure for superior mesenteric artery syndrome. Clin Case Rep 2023; 11:e7651. [PMID: 37465243 PMCID: PMC10350670 DOI: 10.1002/ccr3.7651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 02/15/2023] [Accepted: 05/14/2023] [Indexed: 07/20/2023] Open
Abstract
Key Clinical Message The robotic modified Strong procedure is a safe and effective approach for surgical management of superior mesenteric artery syndrome in properly selected patients. Abstract Superior mesenteric artery syndrome is a rare syndrome of small bowel obstruction resulting from vascular compression of the duodenum. Here we present our modification of a robotic Strong procedure for the surgical management of SMA syndrome. This procedure is a safe and effective approach for management in properly selected patients.
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Affiliation(s)
- Kareem Wasef
- Department of SurgeryWest Virginia UniversityMorgantownWest VirginiaUSA
| | - Aaron Hudnall
- Department of SurgeryWest Virginia UniversityMorgantownWest VirginiaUSA
| | - Carl R. Schmidt
- Department of SurgeryWest Virginia UniversityMorgantownWest VirginiaUSA
| | - J. Wallis Marsh
- Department of SurgeryWest Virginia UniversityMorgantownWest VirginiaUSA
| | - Brian A. Boone
- Department of SurgeryWest Virginia UniversityMorgantownWest VirginiaUSA
- Department of Microbiology, Immunology and Cell BiologyMorgantownWest VirginiaUSA
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Oka A, Awoniyi M, Hasegawa N, Yoshida Y, Tobita H, Ishimura N, Ishihara S. Superior mesenteric artery syndrome: Diagnosis and management. World J Clin Cases 2023; 11:3369-3384. [PMID: 37383896 PMCID: PMC10294176 DOI: 10.12998/wjcc.v11.i15.3369] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/13/2023] [Accepted: 04/18/2023] [Indexed: 05/25/2023] Open
Abstract
Superior mesenteric artery (SMA) syndrome (also known as Wilkie's syndrome, cast syndrome, or aorto-mesenteric compass syndrome) is an obstruction of the duodenum caused by extrinsic compression between the SMA and the aorta. The median age of patients is 23 years old (range 0-91 years old) and predominant in females over males with a ratio of 3:2. The symptoms are variable, consisting of postprandial abdominal pain, nausea and vomiting, early satiety, anorexia, and weight loss and can mimic anorexia nervosa or functional dyspepsia. Because recurrent vomiting leads to aspiration pneumonia or respiratory depression via metabolic alkalosis, early diagnosis is required. The useful diagnostic modalities are computed tomography as a standard tool and ultrasonography, which has advantages in safety and capability of real-time assessments of SMA mobility and duodenum passage. The initial treatment is usually conservative, including postural change, gastroduodenal decompression, and nutrient management (success rates: 70%-80%). If conservative therapy fails, surgical treatment (i.e., laparoscopic duodenojejunostomy) is recommended (success rates: 80%-100%).
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Affiliation(s)
- Akihiko Oka
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Izumo 693-8501, Shimane, Japan
| | - Muyiwa Awoniyi
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgery Institute, Hepatology Section, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Nobuaki Hasegawa
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Izumo 693-8501, Shimane, Japan
| | - Yuri Yoshida
- Clinical Laboratory Division, Shimane University Hospital, Izumo 693-8501, Shimane, Japan
| | - Hiroshi Tobita
- Division of Hepatology, Shimane University Hospital, Izumo 693-8501, Shimane, Japan
| | - Norihisa Ishimura
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Izumo 693-8501, Shimane, Japan
| | - Shunji Ishihara
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Izumo 693-8501, Shimane, Japan
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Hsu D, Zhang KY, Rubesova E, Bruzoni M, Khavari N, Goyal A. Superior Mesenteric Artery Syndrome in an Adolescent With Anorexia and Suspected Pancreatitis. JPGN REPORTS 2022; 3:e194. [PMID: 37168901 PMCID: PMC10158292 DOI: 10.1097/pg9.0000000000000194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/18/2021] [Indexed: 05/13/2023]
Affiliation(s)
- Diane Hsu
- From the Pediatric Gastroenterology, Stanford University, Palo Alto, CA
| | - Ke-You Zhang
- From the Pediatric Gastroenterology, Stanford University, Palo Alto, CA
| | | | - Matias Bruzoni
- Pediatric General Surgery, Stanford University, Palo Alto, CA
| | - Nasim Khavari
- From the Pediatric Gastroenterology, Stanford University, Palo Alto, CA
| | - Alka Goyal
- From the Pediatric Gastroenterology, Stanford University, Palo Alto, CA
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Singh G, Sharma R, Kumar A, Goyal S, Sharma S. Celiac plexus chemical neurolysis for refractory pain associated with superior mesenteric artery syndrome. INDIAN JOURNAL OF PAIN 2022. [DOI: 10.4103/ijpn.ijpn_25_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Kim JY, Shin MS, Lee S. Endoscopic features for early decision to evaluate superior mesenteric artery syndrome in children. BMC Pediatr 2021; 21:392. [PMID: 34496824 PMCID: PMC8424886 DOI: 10.1186/s12887-021-02848-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 08/17/2021] [Indexed: 12/03/2022] Open
Abstract
Background Diagnostic delay of superior mesenteric artery syndrome (SMAS) is common due to its rarity and lack of index of clinical suspicion. Early diagnosis under suspicion is pivotal for adequate treatment. Present study aims to explore the endoscopic features for early decision to evaluate SMAS in children. Methods In case controlled observation study, the recruitment was limited to patients who had endoscopic finding I or finding 1 plus more as follows: a pulsating vertical or oblique band or slit like luminal narrowing of the third part of the duodenum without no expansion over one third during air insufflation for at least 15 s (finding I), a marked dilation of the duodenal first and second part during air insufflation at the third part of the duodenum (finding II), a bile mixed fluid collection (bile lake) in the stomach (finding III). SMAS was confirmed with UGI series or hypotonic duodenography in enrolled patients. We analyzed positive endoscopic findings related with SMAS. Results The enrolled 29 patients consisted of 18 (62.1%) with SMAS and 11 (37.9%) without SMAS. The three most common presenting symptoms were abdominal pain, postprandial discomfort, and early satiety. The clinical impressions based on history and physical examination before endoscopy were functional dyspepsia (34.6%), gastritis or gastric ulcer (31.0%), and SMAS (17.3%). The constellation of three endoscopic findings (finding I + II + III, feature D) observed in 13 (72.2%) patients of SMAS group and 3 (27.3%) patients of non SMAS group (P = 0.027). Of 16 patients with features D, SMAS was diagnosed in 13 patients (81.2%) and not detected in 3 patients (18.8%) on UGI series or hypotonic duodenography. Conclusions Endoscopic examination to the third part of the duodenum can provide a clue making a decision to evaluate SMAS, which consists of features of three endoscopic findings as follows: a pulsating vertical or oblique band or slit like luminal narrowing of the third part of the duodenum without no expansion over one third during air insufflation for at least 15 s, a marked dilation of the first and second part of the duodenum, and a bile lake in the stomach.
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Affiliation(s)
- Jae Young Kim
- Department of Pediatrics, Gyeongsang National University Changwon Hospital, 11 Samjunga-Ro, Sungsan-Gu, Changwon, 51472, South Korea. .,Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, South Korea.
| | - Myung Seok Shin
- Department of Pediatrics, College of Medicine, The Catholic University, St. Mary's Hospital, Daejeon, South Korea
| | - Sunho Lee
- Department of Pediatrics, Gyeongsang National University Changwon Hospital, 11 Samjunga-Ro, Sungsan-Gu, Changwon, 51472, South Korea
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12
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Russell EA, Braverman RM, Vasudevan SA, Patel B. A Traumatic Quinceañera: Acute Superior Mesenteric Artery Syndrome in an Adolescent Girl. Pediatr Emerg Care 2021; 37:e203-e205. [PMID: 30130339 DOI: 10.1097/pec.0000000000001563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT A 15-year-old girl presented with 3 days of progressive abdominal distention, pain, and bilious hematemesis. Her symptoms began after her quinceañera, during which she wore a tight corset. On examination, she was thin and had significant abdominal distention and pain. A computed tomography revealed a massively dilated stomach and proximal duodenum to the region of the superior mesenteric artery (SMA) with distal decompression. An upper gastrointestinal fluoroscopy demonstrated marked dilation of the stomach through the mid third portion of the duodenum with distal decompression and an associated linear compression on her duodenal wall. We believe that she developed acute SMA syndrome. Superior mesenteric artery syndrome is a partial bowel obstruction caused when the third portion of the duodenum is compressed as it passes between the SMA and the aorta. Although the SMA syndrome is most commonly described as a condition associated with chronic, severe weight loss resulting in a narrowing of the SMA to aorta angle and subsequent duodenal compression, it can present acutely from causes such as a postoperative complication, blunt trauma, or external compression. Previously described acute SMA syndrome from external compression has been the result of medically necessary causes, such as body casting. In this case, the tight gown was likely the inciting factor for her development of SMA syndrome; however, she was placed at high risk for the condition by being underweight at baseline and experiencing food restriction for several days preceding her quinceañera. She was treated conservatively with nasogastric decompression and parenteral nutrition, and has since completely recovered.
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Affiliation(s)
- Eric A Russell
- From the Departments of Pediatrics, Sections of Emergency Medicine
| | | | | | - Binita Patel
- From the Departments of Pediatrics, Sections of Emergency Medicine
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Deshpande SH, Thomas J, Chiranjeev R, Pandya JS. Superior mesenteric artery syndrome in a patient with celiacomesenteric trunk. BMJ Case Rep 2021; 14:14/2/e237132. [PMID: 33622741 PMCID: PMC7907866 DOI: 10.1136/bcr-2020-237132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Superior mesenteric artery (SMA) syndrome is an uncommon entity leading to compression of the duodenum between the aorta and the SMA. Normally the coeliac trunk and the superior mesenteric arteries have distinct origins from the abdominal aorta. The celiacomesenteric trunk (CMT) is the least frequently reported anatomic variation of all abdominal vascular anomalies. CMT denotes a common trunk of origin of the coeliac and superior mesenteric arteries. The coexistence of these anomalies has never been reported in the literature. We present a case of a 59-year-old man presenting with duodenal obstruction due to SMA syndrome with CMT. The aortomesenteric angle was 13 degrees and SMA-aorta distance was 8 mm. Patient underwent a gastrojejunostomy. After an uneventful recovery, the patient has been symptom free for 1-year follow-up.
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Affiliation(s)
| | - Jenny Thomas
- General Surgery, BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Roshan Chiranjeev
- General Surgery, BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
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Badour M, Mahmoud G, Hasan A, Sulaiman W, Hammed A. A case of superior mesenteric artery syndrome got physicians in trouble. J Surg Case Rep 2021; 2021:rjaa613. [PMID: 33569168 PMCID: PMC7852606 DOI: 10.1093/jscr/rjaa613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/26/2020] [Accepted: 12/30/2020] [Indexed: 11/13/2022] Open
Abstract
Superior mesenteric artery (SMA) syndrome is a gastrovascular disorder in which the third and final portion of the duodenum is compressed between the abdominal aorta (AA) and the overlying SMA. Our case presents an 11-year-old female with chronic intermittent vomiting that started since she was 6 months old. Contrast enhanced computed tomography scan for abdomen and pelvis guided to the correct diagnosis and the patient received the adequate treatment. Awareness of a broad range of differential diagnosis of vomiting and a high degree of suspicion of SMA syndrome is fundamental in order to direct the proper diagnostic investigation. Duodenojejunostomy provides the best results in severe cases.
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Affiliation(s)
- Maysaa Badour
- Pediatric University Hospital, Division of Gastroenterology, Damascus, Syria
| | - Gaber Mahmoud
- Pediatric University Hospital, Division of Gastroenterology, Damascus, Syria
| | - Ahmad Hasan
- AL-Basel Hospital, Department of Pediatric Surgery, Tartus, Syria
| | - Walaa Sulaiman
- Pediatric University Hospital, Division of Gastroenterology, Damascus, Syria
| | - Ali Hammed
- Tishreen University Hospital, Department of Neurosurgery, Lattakia, Syria
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Wang HK, Huang WH, Chen KT. An extensive posterior circulation infarction secondary to primary hyperthyroidism accompanied with superior mesenteric artery syndrome: A case report and description of patho-physiological association. Medicine (Baltimore) 2020; 99:e22664. [PMID: 33181647 PMCID: PMC7668437 DOI: 10.1097/md.0000000000022664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 08/25/2020] [Accepted: 09/10/2020] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Hyperthyroidism-related anterior circulation ischemic events have been well documented; however, posterior circulation infarction is rarely reported, not to mention with superior mesenteric artery syndrome (SMAS), which has never been reported concurrently. We describe, to the best of our knowledge, the first case of hyperthyroidism-related cerebellar infarction accompanied with SMAS. PATIENT CONCERNS A 22-year-old women presented with palpitation, postprandial vomiting, and acute body weight loss. Enlarged thyroid gland was discovered in physical examination and Graves disease was diagnosed by blood test; therefore, Propylthiouracil and β-blocker were prescribed. Sudden onset conscious disturbance accompanied with apnea was noted during hospitalization. DIAGNOSIS Computed tomography (CT) revealed cerebellar infarction with severe cerebellar swelling and tonsil herniation; hence, emergent suboccipital craniotomy and bilateral tonsillectomy were performed. INTERVENTIONS Nevertheless, persisted poor passage of liquid diet during nasogastric tube feeding was noted after operation. CT of abdomen showed a sharp aorta-SMA angle (15°) and a short distance between aorta and SMA (6 mm) indicating a diagnosis of SMAS. OUTCOMES After parental nutrition supplement and progressive rehabilitation program, she recovered to a modified Rankin Scale of 3. CONCLUSION Although rarely reported, hyperthyroidism-related sympathetic hyperstimulation, vasculopathy could result in potentially deadly posterior circulation infarction. Furthermore, SMAS should be considered in the cases of hyperthyroidism with prolonged gastrointestinal symptoms even after treatment and should be treated simultaneously, since SMAS exacerbates depletion of intravascular volume. Further study to clarify the relation between hyperthyroidism and posterior circulation hemodynamic status is suggested.
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Affiliation(s)
- Hong-Kai Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou
| | | | - Ko-Ting Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou
- Ph.D. Program in Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
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Recurrent Small Bowel Obstruction in an Adolescent Patient. ACG Case Rep J 2020; 7:e00385. [PMID: 32607383 PMCID: PMC7289283 DOI: 10.14309/crj.0000000000000385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/04/2020] [Indexed: 11/17/2022] Open
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Dekonenko C, Hill JA, Sobrino JA, Snyder CL, St Peter SD, Oyetunji TA. Ligament of Treitz Release With Duodenal Lowering for Pediatric Superior Mesenteric Artery Syndrome. J Surg Res 2020; 254:91-95. [PMID: 32422431 DOI: 10.1016/j.jss.2020.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/26/2020] [Accepted: 04/11/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Operative approaches for superior mesenteric artery syndrome (SMAS) vary from Roux-en-Y duodenojejunostomy to the more conservative division of the ligament of Treitz with inferior duodenal derotation known as the Strong procedure. We sought to examine outcomes following a modified version of Strong procedure where the duodenum is lowered as opposed to derotated for the management of SMAS. MATERIALS AND METHODS We conducted a retrospective chart review of children who underwent surgical management of SMAS between January 2008 and December 2017. An online survey regarding symptom resolution, feeding practices, and the need for additional procedures was distributed. Data are reported as medians with interquartile range (IQR) and proportions as percentages. RESULTS Seven patients with a median age of 15 y (IQR 8, 16) and median body mass index of 16.9 (IQR, 12.6, 22.1) were included. Presenting symptoms included pain (71%), nausea (57%), and vomiting (43%). Six patients initially underwent duodenal lowering, whereas one patient underwent duodenoduodenostomy. One patient underwent adhesiolysis for bowel obstruction in the early postoperative period. All patients had symptom resolution at a postoperative follow-up of 22 d (IQR, 15, 45). Two patients had symptom recurrence, and one patient required reoperation. Six patients completed the survey at a median of 2.3 y (IQR, 1.7, 3.2) postoperatively, of which four underwent duodenal lowering. Of these, 75% (n = 3) were asymptomatic. One patient with recurrence reported occasional nausea and emesis but has not required additional surgery. CONCLUSIONS Release of the ligament of Treitz with duodenal lowering results in resolution of symptoms in 75% of patients. This operative approach may be considered before performing more complex operations for SMAS.
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Affiliation(s)
- Charlene Dekonenko
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri
| | - Joshua A Hill
- School of Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | - Justin A Sobrino
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri; Department of Surgery, Quality Improvement and Surgical Equity Research (QISER) Center, Children's Mercy Kansas City, Kansas City, Missouri.
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18
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Bing L, Shun-Lin X, Ji-Hua O, Wei-Bing C, Ye-Bo W. Laparascopic Ladd's procedure as treatment alternative, when parenteral or prolonged hospital nutrition is not an option for superior mesenteric artery syndrome. J Pediatr Surg 2020; 55:554-557. [PMID: 30376960 DOI: 10.1016/j.jpedsurg.2017.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 06/16/2017] [Accepted: 07/10/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Superior mesenteric artery syndrome (SMAS) is an uncommon cause of duodenal obstruction in pediatric patients. It is extremely rare in young infants. The classic treatment for SMAS has been an open or laparoscopic duodenojejunostomy when conservative medical therapy failed to resolve the obstruction. We herein reported 3 cases of SMAS in infants treated by laparoscopic Ladd's procedure. The advantages and feasibility of laparoscopic Ladd's procedure applied for SMAS in infants were discussed. METHODS Three cases of infants with SMAS subjected to laparoscopic Ladd's procedure in our hospital were collected from January 2014 to December 2015. The patients' age, operative time, postoperative hospital observation, resumption of full diet, and postoperative complications were analyzed. RESULTS The median age at operation was 8 months (range, 6-9 months). The mean body weight was 7.9 kg (range, 6.5-8.8 kg). The mean operative time was 66.7 min (range, 65-75 min). The mean postoperative hospital stay was 4.3 days (range, 4-5 days) and the follow-up was 20.7 months (range, 12-34 months) without any specific postoperative complications. CONCLUSION Based on our reports, laparoscopic Ladd's procedure is a reliable and practicable minimally invasive surgery for in infants with SMAS.
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Affiliation(s)
- Li Bing
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, 104 Renmin Road South, Jiang Su, 223002, PR China.
| | - Xia Shun-Lin
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, 104 Renmin Road South, Jiang Su, 223002, PR China
| | - Ou Ji-Hua
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, 104 Renmin Road South, Jiang Su, 223002, PR China
| | - Chen Wei-Bing
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, 104 Renmin Road South, Jiang Su, 223002, PR China
| | - Wang Ye-Bo
- Department of General Surgery, Huai'an First People's Hospital, Nanjing Medical University, 6 Beijing Road West, Huai'an, Jiangsu 223300, PR China
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19
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Madhu B, Govardhan B, Krishna B. Cast syndrome. Oxf Med Case Reports 2019; 2019:omz025. [PMID: 31049210 PMCID: PMC6487991 DOI: 10.1093/omcr/omz025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 02/22/2019] [Accepted: 03/02/2019] [Indexed: 11/30/2022] Open
Abstract
Cast syndrome, commonly known as superior mesenteric artery (SMA) syndrome is a rare cause of small bowel obstruction caused by compression of third part of duodenum from narrowing of the angle between superior mesenteric artery and abdominal aorta resulting in symptoms of duodenal outflow obstruction. A 46-year-old male presented with acute worsening of chronic abdominal pain, nausea and vomiting aggravated with eating. Computed tomography of abdomen and pelvis revealed the dilatation of gastric and proximal duodenum due to compression of third part of duodenum between superior mesenteric artery and aorta. Conservative management with total parental nutrition failed and patient underwent gastrojejunostomy with relief of his symptoms. Cast syndrome is a rare condition but should be kept in mind in patients with abdominal pain, vomiting, early satiety and weight loss. CT abdomen usually reveals the diagnosis but upper GI endoscopy helps to rule out other causes of duodenal obstruction and gastric dilatation.
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Affiliation(s)
- Badireddy Madhu
- Department of Hospital Medicine, Christus Santa Rosa Hospital Westover Hills, San Antonio, TX, USA
| | - Bobbala Govardhan
- Department of Hospital Medicine, Christus Santa Rosa Hospital Westover Hills, San Antonio, TX, USA
| | - Baradhi Krishna
- Department of Nephrology, University of Oklahoma, Tulsa, OK, USA
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Acute Rehabilitation of a 27-Year-Old Man With Failure to Thrive. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2019. [DOI: 10.1097/jat.0000000000000094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Attili A, Ang D. Medial Rotation of the Duodenum with Duodenal Duodenostomy: A Novel Surgical Approach for the Management of Superior Mesenteric Artery Syndrome. Am Surg 2019. [DOI: 10.1177/000313481908500304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Darwin Ang
- University of Central Florida College of Medicine Orlando, Florida
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22
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Oh MJ. Superior Mesenteric Artery Syndrome Combined with Renal Nutcracker Syndrome in a Young Male: A Case Report. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 70:253-260. [PMID: 29161795 DOI: 10.4166/kjg.2017.70.5.253] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Superior mesenteric artery (SMA) syndrome is one of the rare causes of small bowel obstruction. It develops following a marked decrease in the angle between SMA and the abdominal aorta due to weight loss, anatomical anomalies, or following surgeries. Nutcracker syndrome in the left renal vein may also occur following a decrease in the aortomesenteric angle. Though SMA syndrome and renal nutcracker syndrome share the same pathogenesis, concurrent development has rarely been reported. Herein, we report a 23-year-old healthy male diagnosed with SMA syndrome and renal nutcracker syndrome due to severe weight reduction. The patient visited our outpatient clinic presenting bilious vomiting and indigested vomitus for 3 consecutive days. He had lost 20 kg during military service. We suspected SMA syndrome based on abnormal air-shadow in the stomach and small bowel on abdominal X-ray; we confirmed compression of the third portion of the duodenum with upper gastrointestinal series and abdominal computed tomography (CT). Concurrently, renal nutcracker syndrome was also detected via abdominal CT and Doppler ultrasound. Considering bilious vomiting and no urinary symptoms, SMA syndrome was corrected by laparoscopic duodenojejunostomy, and close observation for the renal nutcracker syndrome was recommended.
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Affiliation(s)
- Myung Jin Oh
- Division of Gastroenterology, Department of Internal Medicine, CHA Gumi Medical Center, CHA University School of Medicine, Gumi, Korea
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23
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Konstantinidis H, Charisis C, Kottos P. Robotic Strong's procedure for the treatment of superior mesenteric artery syndrome. Description of surgical technique on occasion of the first reported case in the literature. Int J Med Robot 2017; 14. [PMID: 29168288 DOI: 10.1002/rcs.1876] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/14/2017] [Accepted: 10/12/2017] [Indexed: 01/02/2023]
Abstract
BACKROUND Superior Mesenteric Artery Syndrome (SMAS) is a rare disorder caused by compression of the third portion of the duodenum by the SMA. Once a conservative approach fails, usual surgical strategies include Duodenojejunostomy and Strong's procedure. The latter avoids potential anastomotic risks and complications. Robotic Strong's procedure (RSP) combines both the benefits of a minimal invasive approach and also enchased robotic accuracy and efficacy. METHODS For a young girl who was unsuccessfully treated conservatively, the paper describes the RSP surgical technique. To the authors' knowledge, this is the first report in the literature. RESULTS Minimal blood loss, short operative time, short hospital stay and early recovery were the short-term benefits. Significant weight gain was achieved three months after the surgery. CONCLUSION Based on primary experience, it is suggested that RSP is a very effective alternative in treating SMAS.
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Affiliation(s)
- Harilaos Konstantinidis
- Interbalkan Medical Centre, Robotic General and Oncologic Surgical Department, Thessaloniki, Greece
| | - Christos Charisis
- Interbalkan Medical Centre, Robotic General and Oncologic Surgical Department, Thessaloniki, Greece
| | - Panagiotis Kottos
- Interbalkan Medical Centre, Robotic General and Oncologic Surgical Department, Thessaloniki, Greece
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24
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Valiathan G, Wani M, Lanker J, Reddy PK. A Case Series on Superior Mesenteric Artery Syndrome Surgical Management, Single Institution Experience. J Clin Diagn Res 2017; 11:PR01-PR03. [PMID: 28969208 DOI: 10.7860/jcdr/2017/20248.10402] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 07/15/2017] [Indexed: 11/24/2022]
Abstract
Compression of duodenum by Superior Mesenteric Artery (SMA) causing proximal intestinal obstruction is an uncommon condition. Treatment of this condition involves conservative management initially followed by surgical management in those patients who have persistent symptoms. This case series evaluates surgical management and outcome of six patients after one year, who presented with SMA syndrome and describes a brief review of literature. Three patients underwent open duodenojejunostomy and the rest three underwent laparoscopic duodenojejunostomy. All patients had uneventful postoperative recovery. Postoperative requirement of analgesics was less in laparoscopic group versus open group. All the three patients in laparoscopic group could be mobilised out of bed on the day of the surgery itself. Mean duration of hospital stay was seven days for open surgery group and three days for the laparoscopy group. Outcome in terms of resolution of abdomen pain and vomiting was similar in both the groups. Four patients were asymptomatic after one year of follow up. A high index of clinical suspicion is needed for the diagnosis of SMA syndrome. Laparoscopic approach is feasible, safe, less morbid and effective as compared to open surgery. In the presence of facilities and surgical expertise, laparoscopic duodenojejunostomy should be considered the procedure of choice for SMA syndrome. Majority of patients remain symptom free at one year follow up.
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Affiliation(s)
- Gopakumar Valiathan
- Registrar, Department of Surgical Gastroenterology, Apollo Main Hospitals, Chennai, Tamil Nadu, India
| | - Majid Wani
- Registrar, Department of Surgical Gastroenterology, Minimal Access Surgery, Apollo Main Hospitals, Chennai, Tamil Nadu, India
| | - Juneed Lanker
- Registrar, Department of Surgical Gastroenterology, Minimal Access Surgery, Apollo Main Hospitals, Chennai, Tamil Nadu, India
| | - Prasanna Kumar Reddy
- Senior Consultant, Surgical Gastroenterologist and Laparoscopic Surgeon, Department of Surgical Gastroenterology, Apollo Hospitals, Chennai, Tamil Nadu, India
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25
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Ovalle-Chao C, Hinojosa-Martinez LM, Gutierrez-Castillo A, Velazco-De La Garza JH, Flores-Villalba E, Diaz-Elizondo JA, Garza-Serna U. Acute-onset of superior mesenteric artery syndrome following surgical correction of scoliosis: Case report and review of literature. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2017. [DOI: 10.1016/j.epsc.2017.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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26
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Salem A, Al Ozaibi L, Nassif SMM, Osman RAGS, Al Abed NM, Badri FM. Superior mesenteric artery syndrome: A diagnosis to be kept in mind (Case report and literature review). Int J Surg Case Rep 2017; 34:84-86. [PMID: 28376419 PMCID: PMC5379908 DOI: 10.1016/j.ijscr.2017.03.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 03/12/2017] [Accepted: 03/14/2017] [Indexed: 11/10/2022] Open
Abstract
Superior mesenteric artery syndrome is rare cause of duodenal obstruction. Superior mesenteric artery syndrome is caused by narrowing of aortomesenteric angle. High index of suspicion is needed for diagnosis. Most common cause is significant weight loss. Simple Contrast enhanced CT scan can help in reaching diagnosis. Introduction Superior mesenteric artery (SMA) syndrome or what is called Wiklie’s syndrome is one of the rare causes of small bowel obstruction. Its exact incidence is not known. It is due to decrease in Aortomesenteric angle. Case presentation A thirty-Four-year old male patient presented to our accident and emergency (department) with 3 days history of epigastric pain, which was not radiating anywhere. It had no aggravating or relieving factors. Patient complained of repeated attack of vomiting as well. Contrast enhanced Computed tomography (CT) showed duodenal obstruction caused by superior mesenteric artery compression on 3rd part of duodenum. Discussion Superior mesenteric artery syndrome (SMA) is one of the rare causes of small bowel obstruction. Incidence of superior mesenteric artery syndrome reported in literature is ranging from 0.1 to 0.3%. The most common cause is significant weight loss which leads to loss of retroperitoneal fat. Treatment usually is conservative but surgical intervention should be considered if that failed. Conclusion Superior mesenteric artery syndrome is a rare cause of intestinal obstruction but should be kept in mind. Persistent vomiting after history of weight loss should raise the suspicion of this diagnosis. Upper GI endoscopy may be necessary to exclude mechanical causes of duodenal obstruction. Contrast enhanced CT scan is useful in the diagnosis of superior mesenteric artery syndrome and can provide diagnostic information.
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Affiliation(s)
- Ali Salem
- General Surgery Department, Rashid Hosiptal, Dubai, United Arab Emirates.
| | - Labib Al Ozaibi
- General Surgery Department, Rashid Hosiptal, Dubai, United Arab Emirates.
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27
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Kaur A, Pawar NC, Singla S, Mohi JK, Sharma S. Superior Mesentric Artery Syndrome in a Patient with Subacute Intestinal Obstruction: A Case Report. J Clin Diagn Res 2016; 10:TD03-5. [PMID: 27504378 DOI: 10.7860/jcdr/2016/19699.7932] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 04/25/2016] [Indexed: 11/24/2022]
Abstract
Superior Mesenteric Artery (SMA) syndrome is one of the rare cause of proximal small bowel obstruction wherein, the third part of the duodenum is compressed between the SMA at its origin and abdominal aorta due to decreased angulations in these two vessels. This decreased angulation exerts a compression effect on third part of the duodenum, resulting in duodenal obstruction which may be complete or partial. There are number of causes which can lead to this entity and will be discussed briefly. Here we report imaging findings of such a rare cause of proximal small bowel obstruction in a young male patient who presented to the emergency surgical department with non specific symptoms of pain abdomen and abdominal fullness. Patient was evaluated under the standard protocol in management of abdominal pain. General physical examination, erect and supine radiograph were taken. On barium meal follow-through examination, there was paucity of contrast agent distal to the second part of duodenum with proximal dilation of stomach, first and second part of duodenum which raised us the possibility of SMA syndrome. Reconstructed CECT abdomen confirmed the decreased angulation between SMA and abdominal aorta and diagnosed it as SMA syndrome. Findings were correlated on duodenojejunostomy anastomotic surgical procedure. Diagnosing and reporting such a case of SMA syndrome is of utmost importance because the clinical presentation being non-specific pertaining to small bowel obstruction which may pose a diagnostic difficulty to the surgeon and with the further delay in diagnosis, patients may end up with chronic symptoms and complications of the disease, repeated hospital visits and electrolyte abnormalities.
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Affiliation(s)
- Amarjit Kaur
- Professor, Department of Radiodiagnosis, GMC Patiala, Punjab, India
| | | | - Sonam Singla
- Junior Resident, Department of Radiodiagnosis, GMC , Patiala, Punjab, India
| | - Jaswinder Kaur Mohi
- Associate Professor, Department of Radiodiagnosis, GMC Patiala, Punjab, India
| | - Shivani Sharma
- Junior Resident, Department of Radiodiagnosis, GMC Patiala, Punjab, India
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Abstract
A 56-year-old transgender woman with mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes syndrome and diabetes presented to hospital with headaches and experiencing with malnutrition. She was agitated and refused medical and physical assistance. Soon after admission, she started to vomit and developed abdominal pain, becoming rapidly unresponsive on the ward after attending the radiology department, and was pronounced deceased. Autopsy revealed a cachectic transgender woman with a grossly distended stomach and proximal duodenum containing 2 L of liquid. The postmortem computed tomography scan showed compression of the duodenum by the superior mesenteric artery, diagnostic of Wilkie syndrome. Superior mesenteric artery syndrome, or Wilkie syndrome, was first described in 1861 by Von Rokitansky. It is an uncommon but well-recognized clinical entity characterized by compression of the third, or transverse, portion of the duodenum between the aorta and the superior mesenteric artery. This results in chronic, intermittent, or acute complete or partial duodenal obstruction. It is a well-recognized complication of anorexia.
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29
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KEFELI A, AKTÜRK A, AKTAŞ B, ÇALAR K. WILKIE'S SYNDROME: A RARE CAUSE OF INTESTINAL OBSTRUCTION. ABCD. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA (SÃO PAULO) 2016; 29:68. [PMID: 27120748 PMCID: PMC4851159 DOI: 10.1590/0102-6720201600010020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 11/19/2015] [Indexed: 11/22/2022]
Affiliation(s)
- Ayşe KEFELI
- Abdullah Özgür Yeniova Gaziosmanpaşa University, Turkey
| | - Adem AKTÜRK
- Abdullah Özgür Yeniova Gaziosmanpaşa University, Turkey
| | - Bora AKTAŞ
- Abdullah Özgür Yeniova Gaziosmanpaşa University, Turkey
| | - Kerim ÇALAR
- Abdullah Özgür Yeniova Gaziosmanpaşa University, Turkey
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30
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Abol Oyoun N, Kadhim M, Dormans JP. Late-onset superior mesenteric artery syndrome four years following scoliosis surgery - a case report. SICOT J 2015; 1:12. [PMID: 27163068 PMCID: PMC4849222 DOI: 10.1051/sicotj/2015010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 04/29/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Superior mesenteric artery (SMA) syndrome has been reported as an uncommon condition of external vascular compression of the SMA particularly after rapid weight loss, body casts, or after corrective surgery for spinal deformities, usually within the first few weeks after surgery. METHODS This is a retrospective report of a case of a non-verbal autistic female patient who started to develop SMA syndrome at the age of 16, 4 years after posterior spinal fusion surgery for scoliosis. She was treated conservatively by increasing oral caloric intake, which resulted in increased body weight and relief of symptoms. RESULTS Seen at 10 years' follow up, the patient is doing well, and is functional within the limits of her suboptimal cognitive and verbal conditions. She maintains good trunk balance with solid spinal fusion and intact instrumentation at latest follow up. CONCLUSION Spinal surgeons should maintain a high index of suspicion for diagnosis of SMA syndrome even years after scoliosis surgery, especially for patients with communication problems, like the case we present here. Appropriate conservative measures can succeed in relieving the symptoms, increasing body weight, and preventing complications including the risk of death.
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Affiliation(s)
- Nariman Abol Oyoun
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Department of Orthopaedic Surgery, Assiut University Hospital Assiut
71526 Egypt
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Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia 3401 Civic Center Boulevard Philadelphia
PA 19104 USA
| | - Muayad Kadhim
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Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia 3401 Civic Center Boulevard Philadelphia
PA 19104 USA
| | - John P. Dormans
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Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia 3401 Civic Center Boulevard Philadelphia
PA 19104 USA
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31
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Chowdhary M, Pansuria HP, Farooqi B, Goyal H. Superior mesenteric artery syndrome: a unique complication following carboplatin-based chemotherapy. Int Med Case Rep J 2015; 8:55-8. [PMID: 25733933 PMCID: PMC4337516 DOI: 10.2147/imcrj.s80572] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Superior mesenteric artery syndrome (SMAS) is an uncommon condition, attributable to vascular compression of the third part of the duodenum between the superior mesenteric artery and the abdominal aorta. It can present in patients due to mechanical compression or severe weight loss. We present a unique case of SMAS in a patient undergoing carboplatin-based chemotherapy for mesothelioma. An 81-year-old male with mesothelioma was treated with carboplatin-based chemotherapy. He subsequently suffered a progressive, unintentional 18 kg weight loss and presented acutely with intense epigastric pain, severe nausea, and vomiting. Diagnosis was confirmed by abdominal computed tomography and esophagogram with upper gastrointestinal series, which revealed gastric and duodenal distention and a narrow angle between the superior mesenteric artery and aorta, causing compression of the duodenum. Prompt recognition of this syndrome allowed us to treat our patient successfully and avoid the risks of operative interventions. To our knowledge, this is the first reported case of SMAS in patients receiving carboplatin. Furthermore, this case of SMAS was unique in that it was due to weight loss as compared with mechanical obstruction. Our experience illustrates the importance of considering SMAS in chemotherapy patients, especially those with substantial weight loss. A high index of suspicion for this potential complication coupled with appropriate radiographic studies are necessary for early diagnosis and can prevent severe consequences.
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Affiliation(s)
- Mudit Chowdhary
- Department of Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Heer P Pansuria
- Department of Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Bilal Farooqi
- Department of Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Hemant Goyal
- Department of Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
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32
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Kamezaki H, Azemoto R, Yokosuka O, Fujimoto T, Obu M, Saito M, Yoshida Y, Koma Y, Maruyama H, Fujimori M. Suspicion of superior mesenteric artery syndrome in a patient with severe gastric dilatation after catheter ablation. Intern Med 2015; 54:605-9. [PMID: 25786450 DOI: 10.2169/internalmedicine.54.3276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Catheter ablation is a widely used treatment for atrial fibrillation. Gastric hypomotility due to periesophageal vagal plexus injury is a consequence of the extracardiac penetration of ablative energy. Some affected patients develop severe gastric dilatation requiring hospitalization. However, most previous reports have stated the cause of the subject's condition to be "unknown" or described the symptoms using obscure terms, such as "paralytic" or "gastroparesis." For example, one report stated that a few sites of severe gastric dilatation were secondary to "pyloric spasms;" however, no illustrations were provided in the paper. "Superior mesenteric artery syndrome" is a suspected cause of such dilatation.
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Affiliation(s)
- Hidehiro Kamezaki
- Department of Gastroenterology, Kimitsu Chuo Hospital, Japan; Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Japan
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33
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Sanjad-sakati syndrome and its association with superior mesenteric artery syndrome. Case Rep Pediatr 2014; 2014:108051. [PMID: 25436165 PMCID: PMC4241564 DOI: 10.1155/2014/108051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 10/21/2014] [Indexed: 11/17/2022] Open
Abstract
Sanjad-Sakati syndrome (SSS) is an autosomal recessive disorder found exclusively in people of Arabian origin. It was first reported in the Kingdom of Saudi Arabia in 1988 and confirmed by a definitive report in 1991. The syndrome comprises of congenital hypoparathyroidism, seizures, severe growth and developmental retardation, low IQ, and atypical facial features. Supportive treatment in the form of vitamin D and growth hormone supplementation is often offered to patients suffering from SSS. This case study focuses on the steps taken to help a patient who was found to have very unusual symptoms and was later found to have superior mesenteric artery syndrome.
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34
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Bakker MEC, van Delft R, Vaessens NAL, Rosias PRR. Superior mesenteric artery syndrome in a 15-year-old boy during Ramadan. Eur J Pediatr 2014; 173:1619-21. [PMID: 24169731 DOI: 10.1007/s00431-013-2190-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 10/15/2013] [Indexed: 11/24/2022]
Abstract
UNLABELLED A previously healthy 15-year-old boy who participated in Ramadan and recently suffered from a gastro-enteritis presented at the emergency room with abdominal pain, vomiting, and marked weight loss. Abdominal X-ray and computed tomography showed upper gastrointestinal obstruction and narrowing of the distance between superior mesenteric artery and aorta abdominalis. Through these findings, superior mesenteric artery syndrome was diagnosed. Treatment consisted of placement of a nasojejunal tube for enteral feeding until weight gain was substantial. Superior mesenteric artery syndrome is rare, with a prevalence varying between 0.013 and 0.3 %. It is characterized by compression of the third part of duodenum between aorta and superior mesenteric artery, thus causing signs and symptoms of upper gastrointestinal obstruction. CONCLUSION In general, when signs and symptoms of upper gastrointestinal obstruction are accompanied with rapid weight loss, superior mesenteric artery syndrome should be considered.
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Affiliation(s)
- M E C Bakker
- Department of Pediatrics, Orbis Medical Center, PO Box 5500, 6130MB, Sittard, The Netherlands,
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Devadass CW, Okaly GVP, Hm S, Pai SA, Sridher H. Wilkie's Syndrome and Left Adnexal Mass: Unusual Presentation of Duodenal Adenocarcinoma. J Clin Diagn Res 2014; 8:FD01-2. [PMID: 25302201 DOI: 10.7860/jcdr/2014/9474.4693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 06/12/2014] [Indexed: 11/24/2022]
Abstract
Duodenal adenocarcinoma (DACa) is a rare malignancy, the presenting symptoms of which are vague and nonspecific. We report the case of a patient presenting with symptoms of subacute small bowel obstruction whose CT scan revealed i) left adnexal mass and ii) compression of 3(rd) portion of duodenum with reduced aortomesentric angle consistent with Wilkie's syndrome (WS). Laparatomy in addition revealed a distal duodenal stricture, which showed a well differentiated DACa causing subtotal intestinal obstruction. The ovarian mass revealed adenocarcinoma with similar morphology. Immunophenotypic analysis revealed positive expression of CK 20 and CDX 2 and absence of CK 7 staining in the tumours consistent with Primary DACa with ovarian metastasis. We further concluded that the WS resulted from reduced mesenteric fat pad caused by DACa induced cachexia. The case highlights the elusive nature of duodenal malignancy and emphasises the importance of meticulous small bowel examination during exploration of ovarian masses.
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Affiliation(s)
- Clement Wilfred Devadass
- Associate Professor, Department of Pathology, M.S., Ramaiah Medical College and Teaching Hospital , Bangalore, India
| | - Geetha V Patil Okaly
- Assistant Professor, Department of Pathology, M.S. Ramaiah Medical College and Teaching Hospital , Bangalore, India
| | - Sudha Hm
- Professor, Department of Pathology, M.S. Ramaiah Medical College and Teaching Hospital , Bangalore, India
| | - Sreekar Agumbe Pai
- Associate Professor, Department of Surgery, M.S. Ramaiah Medical College and Teaching Hospital , Bangalore, India
| | - H Sridher
- Assistant Professor, Department of Pathology, M.S., Ramaiah Medical College and Teaching Hospital , Bangalore, India
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Madhab G, Madsen J, Brems Dalgaard E, Bharadwaz A. Superior Mesenteric Artery Syndrome: A Rare Mimic of Common Causes of Upper Gastrointestinal Obstruction. Euroasian J Hepatogastroenterol 2014; 4:58-60. [PMID: 29264321 PMCID: PMC5736958 DOI: 10.5005/jp-journals-10018-1098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 02/17/2014] [Indexed: 11/23/2022] Open
Abstract
Rare causes of common symptoms often pose a diagnostic dilemma which can lead to unwanted loss of precious time in proper diagnosis and management. Superior mesenteric artery (SMA) syndrome is such a rare disorder. It typically presents with signs and symptoms of upper gastrointestinal (GI) obstruction which can be mimicked by a variety of clinical conditions, such as peptic ulcer, chronic pancreatitis, mesenteric ischemia and systemic lupus erythematosus (SLE). A high degree of clinical suspicion is required to direct proper investigations to narrow down to the correct diagnosis. Multi-detector CT (MDCT) proves to be invaluable not only in ruling out more common conditions mimicking SMA syndrome but also in arriving at the correct diagnosis quickly and effectively with great clinical accuracy and thereby removing confusion and delay in proper management.
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Affiliation(s)
- Gayatri Madhab
- Department of Radiology, Viborg Regional Hospital, Viborg, Denmark
| | - Jette Madsen
- Department of Radiology, Viborg Regional Hospital, Viborg, Denmark
| | | | - Arindam Bharadwaz
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
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Shah D, Naware S, Thind S, Kuber R. Superior mesenteric artery syndrome: an uncommon cause of abdominal pain mimicking gastric outlet obstruction. Ann Med Health Sci Res 2013; 3:S24-6. [PMID: 24349841 PMCID: PMC3853600 DOI: 10.4103/2141-9248.121214] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Upper gastrointestinal symptoms like vomiting, abdominal pain, abdominal distention may be caused by many conditions like complicated peptic/duodenal ulcer, gastritis or hiatal hernia. However, these symptoms are uncommonly produced by superior mesenteric artery (SMA) syndrome. SMA syndrome is triggered when there is narrowing of the mesenteric angle and shortening of the aortomesenteric distance. We report a case of 42-year-old female who presented with features of gastric outlet obstruction which on further investigation was revealed as SMA syndrome. The aetiology, presentation, diagnosis and management of this unusual condition are discussed.
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Affiliation(s)
- D Shah
- Department of Radio-Diagnosis, Padmashree Dr. D.Y. Patil Hospital and Research Centre, Pimpri, Pune, Maharashtra, India
| | - S Naware
- Department of Radio-Diagnosis, Padmashree Dr. D.Y. Patil Hospital and Research Centre, Pimpri, Pune, Maharashtra, India
| | - S Thind
- Department of Radio-Diagnosis, Padmashree Dr. D.Y. Patil Hospital and Research Centre, Pimpri, Pune, Maharashtra, India
| | - R Kuber
- Department of Radio-Diagnosis, Padmashree Dr. D.Y. Patil Hospital and Research Centre, Pimpri, Pune, Maharashtra, India
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Jain V, Singal AK, Ramu C, Raghunaathan KD. Superior mesenteric artery syndrome: a rare complication in a child with Marfan syndrome. Arch Dis Child 2013; 98:754-5. [PMID: 23814081 DOI: 10.1136/archdischild-2013-304321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Viral Jain
- Department of Pediatrics, MGM University of Health Sciences, Kamothe, , Navi Mumbai, Maharashtra, India
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Mathenge N, Osiro S, Rodriguez II, Salib C, Tubbs RS, Loukas M. Superior mesenteric artery syndrome and its associated gastrointestinal implications. Clin Anat 2013; 27:1244-52. [PMID: 23959808 DOI: 10.1002/ca.22249] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 03/01/2013] [Accepted: 03/03/2013] [Indexed: 11/05/2022]
Abstract
The superior mesenteric artery (SMA) syndrome is a rare but potentially life-threatening gastrointestinal condition. Over the years, it has been referenced by several names, the most common of which is Wilkie's syndrome. These numerous terminologies have made it difficult to estimate its true frequency in the general population. Common symptoms associated with this syndrome include intermittent postprandial abdominal pain, nausea, and bilious vomiting. Our review revealed that although it is currently well-defined in the literature, the diagnosis of SMA syndrome remains challenging as other disorders can mimic its presentation. However, CT angiography is currently favored in the literature for diagnosis as it can not only show the narrowed aorto-mesenteric angle and distance, but also the extent of duodenal obstruction. In addition, we found no consensus on the preferred mode of therapy once SMA syndrome is diagnosed. The agreement among authors is that the treatment options should be based on severity of the disease, using conservative measures as the first line of therapy in mild SMA syndrome. Duodenojejunostomy is the preferred surgical approach when conservative management fails, or in severe cases.
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Affiliation(s)
- Njambi Mathenge
- Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, West Indies
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Shin MS, Kim JY. Optimal duration of medical treatment in superior mesenteric artery syndrome in children. J Korean Med Sci 2013; 28:1220-5. [PMID: 23960451 PMCID: PMC3744712 DOI: 10.3346/jkms.2013.28.8.1220] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 06/13/2013] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to investigate the outcome, and optimal duration of medical treatment in children with superior mesenteric artery syndrome (SMAS). Eighteen children with SMAS were retrospectively studied. The data reviewed included demographics, presenting symptoms, co-morbid conditions, clinical courses, nutritional status, treatments, and outcomes. The three most common symptoms were postprandial discomfort (67.7%), abdominal pain (61.1%), and early satiety (50%). The median duration of symptoms before diagnosis was 68 days. The most common co-morbid condition was weight loss (50%), followed by growth spurt (22.2%) and bile reflux gastropathy (16.7%). Body mass index (BMI) was normal in 72.2% of the patients. Medical management was successful in 13 patients (72.2%). The median duration of treatment was 45 days. Nine patients (50%) had good outcomes without recurrence, 5 patients (27.8%) had moderate outcomes, and 4 patients (22.2%) had poor outcomes. A time limit of >6 weeks for the duration of medical management tended to be associated with worse outcomes (P=0.018). SMAS often developed in patients with normal BMI or no weight loss. Medical treatment has a high success rate, and children with SMAS should be treated medically for at least 6 weeks before surgical treatment is considered.
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Affiliation(s)
- Myung Seok Shin
- Department of Pediatrics, College of Medicine, Catholic University of Korea, St. Mary's Hospital, Daejeon, Korea
| | - Jae Young Kim
- Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
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Abstract
OBJECTIVES Superior mesenteric artery syndrome (SMAS) is a rare cause of small intestinal obstruction in pediatric patients. Children with intellectual disabilities are a challenging patient population in which to make this diagnosis. The goal of this study was to determine the frequency, presenting symptoms, and outcomes of SMAS in intellectually disabled and non-intellectually disabled children. METHODS Retrospective chart review of pediatric patients with SMAS admitted to Penn State Hershey Children's Hospital between January 1999 and July 2010. RESULTS Sixteen children with SMAS were identified. The majority were male (n = 9) and more than two thirds had an intellectual disability (n = 11). Presenting symptoms were similar between groups, but 78% (7/9) of intellectually disabled patients who had a gastrostomy tube presented with feeding intolerance. Although intellectually disabled patients had a higher number of comorbidities and the number of health care visits before diagnosis was higher, this did not reach statistical significance. There were also no significant differences in length of symptoms before diagnosis and amount of weight loss. However, the weight-for-age percentiles in intellectual disabled children were significantly lower in those without an intellectual disability (9.09 [20.31] vs 48 [20.19], respectively, P ≤ 0.001). Seventy-five percent of patients responded favorably to conservative treatment, but 36% (4/11) of intellectually disabled patients required multiple treatments before there was an improvement in their condition. CONCLUSIONS Superior mesenteric artery syndrome was found more often in children with an intellectual disability. These data highlight the need to consider SMAS if there is difficulty tolerating gastrostomy tube feedings in patients with weight-for-age percentiles less than 5%.
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