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      Clinical and Radiologic Considerations for Idiopathic Superior Mesenteric Artery Syndrome

      case-report
      Author(s): 1 , , 2 , 1 , 1
      Editor(s): ,
      Publication date (Electronic, pub):
      Publication date (Electronic, collection):
      Journal: Cureus
      Publisher: Cureus
      Keywords: sma syndrome, superior mesenteric artery, duodenal obstruction, wilkie’s syndrome

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          Abstract

          Superior mesenteric artery (SMA) syndrome often occurs in the setting of rapid weight loss and scoliosis corrective spinal surgery. A reduction of fat around the third part of the duodenum can predispose the duodenum to compression and obstruction by the SMA as it emerges from the abdominal aorta. In this report, we describe this underdiagnosed condition in a previously healthy young female presenting with progressive post-prandial emesis, non-specific abdominal pain, and weight loss. A critical review of this disease process is explored to highlight pathology, imaging characteristics, and essential alternative diagnostic considerations. We also discuss potential complications and current treatment strategies. SMA syndrome poses unique diagnostic challenges, and an awareness of its clinical presentation can further improve patient outcomes and avoid potentially life-threatening complications.

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          Recalling Superior Mesenteric Artery Syndrome

          Thilo Welsch, Markus W. Büchler, Peter Kienle (2007)
          Background: Superior mesenteric artery syndrome is uncommon and characterized by postprandial epigastric pain, nausea, vomiting, anorexia and weight loss. The syndrome is caused by compression of the third part of the duodenum in the angle between the aorta and the superior mesenteric artery. This review updates etiology, epidemiology, diagnosis, treatment and outcome of the superior mesenteric artery syndrome. Methods: Review of the literature. Results: Frequently, predisposing medical conditions associated with catabolic states or rapid weight loss result in a decrease of the aortomesenteric angle and subsequent duodenal obstruction. External cast compression, anatomic variants and surgical alteration of the anatomy following spine surgery or ileoanal pouch anastomosis can also precipitate the syndrome. Once radiologic studies have established diagnosis, first-line treatment is usually conservative with jejunal or parenteral nutrition for restoration of the aortomesenteric fatty tissue. If conservative management fails, surgical options include open or laparoscopic duodenojejunostomy or duodenal mobilization and division of the ligament of Treitz. Conclusion: Superior mesenteric artery syndrome is clearly defined and frequently associated with a wide range of predisposing conditions and surgical procedures; clinicians have to consider this syndrome in such a setting. Larger studies are needed to better define the optimal treatment for this disease.
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            Superior mesenteric artery syndrome: diagnosis and treatment strategies.

            S Biankin, R. Wilson, P H Cosman … (2009)
            Superior mesenteric artery (SMA) syndrome is an unusual cause of vomiting and weight loss resulting from the compression of the third part of the duodenum by the SMA. Various medical and psychiatric conditions may result in the initial rapid weight loss which causes narrowing of the aortomesenteric angle. The vomiting and obstructive syndrome is then self-perpetuated regardless of the initiating factors. The young age and nonspecific symptoms often lead to a delay in diagnosis. A series of eight cases is presented reviewing the presentation, investigations, surgical treatment by division of duodenum and duodenojejunostomy, and outcomes. SMA syndrome is a well-described entity which must be considered as a cause of vomiting associated with significant weight loss in young adults. Surgical treatment should be allied with psychological assessment to treat any underlying psychosocial abnormality.
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              Superior mesenteric artery syndrome: CT and ultrasonography findings.

              Birsen Unal Daphan, Gökhan Kemal, Cagatay Daphan … (2005)
              The purpose of the study was to describe computed tomography (CT) and ultrasonography findings in superior mesenteric artery syndrome (SMAS). 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. 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). 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.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cureus
                Journal ID (iso-abbrev): Cureus
                Journal ID (issn): 2168-8184
                Title: Cureus
                Publisher: Cureus (Palo Alto (CA) )
                ISSN (Electronic): 2168-8184
                Publication date (Electronic, pub): 5 November 2017
                Publication date (Electronic, collection): November 2017
                Volume: 9
                Issue: 11
                Electronic Location Identifier: e1822
                Affiliations
                [1 ] Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, Usa
                [2 ] College of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, Usa
                Author notes
                Article
                DOI: 10.7759/cureus.1822
                PMC ID: 5755943
                SO-VID: afa86e0c-1ed1-4ba7-a725-68026887d792
                Copyright © Copyright © 2017, Makary et al.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 26 September 2017
                Date accepted : 5 November 2017
                Categories
                Subject: Gastroenterology
                Subject: Radiology
                Subject: Gastroenterology

                Keywords: sma syndrome,superior mesenteric artery,duodenal obstruction,wilkie’s syndrome
                Data availability:
                Keywords: sma syndrome, superior mesenteric artery, duodenal obstruction, wilkie’s syndrome

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