Case Report -Superior Mesentric Artery Syndrome

Dr. Netaji Patil - Radiologist

History -

A 19 years young male patient came to B.K.L.Walawalkar Hospital, Dervan with chief complaints of vomiting 1 to 2 hours, after taking food. Vomiting was billious in nature. History of abdominal pain in epigastric region .History of severe recent weight loss. All these symptoms were since last 1 ½ months.

• No history of vomiting, tuberculosis or jaundice, or any other major illness
• O/E-  TPR & BP was normal
• CVS-  S1 & S2 normal
• P/A – No lump.
• No hepato splenomegaly
• Abdomen was soft,  nontender
• Respiratory system – NAD

Investigation -

Barium meal Exam -

 

C. T. Examination -

C. T. Findings -

Marked narrowing of the third portion of the duodenum which appears to be compressed in aortico-mesentric triangle.

 

Impression -

CT & Barium study show third part of duodenal obstruction due to compression in aortico-Mesentric triangle highly suggestive of Superior Mesentric artery syndrome.

 

Discussion -

Superior Mesenteric Artery Syndrome-
Third part of duodenum lies in fixed position & is bounded anteriorly by the root of mesentery carrying the superior mesenteric artery & posteriorly by aorta and lumbar spine. When this compartment becomes narrowed, the third part of duodenum may be obstructed,   this is known as SMA syndrome. SMA is also known as Vascular compression of duodenum = Wilkie  Syndrome =  Chronic duodenal ileus =  body cast syndrome. Vascular compression of 3rd portion of duodenum within aortomesentric compartment; probably representing a functional reflux dilatation etiology. Narrowing of angle between SMA + aorta to 10- 22 degree (normal angle is 45-65 degree) .Most patients are asthenic and symptoms often develop following weight loss, particularly when the patient is bed ridden with a chronic wasting disease. Patient presents with history of repetitive vomiting, abdominal cramps. Initial treatment is aimed at weight gain and duodenojejunostomy is reserved for patients who fail to respond to dietary treatment.

 Narrowing of the compartment may be caused by -

1. An aneurysm of aorta or a retroperitoneal tumor.
2. The association is also been reported with
   • peptic ulceration
   • prolonged  bed rest ( often in a body plaster cast)
   • severe weight loss
   • diminished peristalsis as may be seen with scleroderma

The duodenum dilates proximal to a broad, vertical band like narrowing which crosses the third part of duodenum, as it passes over the spine. In most cases exception of those with scleroderma, fluoroscopy shows vigorous to & fro peristalsis proximal to site of obstruction. In some obstruction is related to posture & by turning patient prone or on to left side the obstruction is released. The attacks of abdominal pain & vomiting encounter in this condition then tend to be intermitant & radiological features are best detected during an attack.

Differential Diagnosis of Duodenal Narrowing are -
      A)Developmental Anomalies --
                1) Duodenal atresia,
                2) Congenital web/duodenal diaphragm,   
                3) Intraluminal diverticulum, 
                4) Duodenal duplication Cyst,
                5) Annular Pancreas,
                6) Midgut  volvulus,   Peritoneal  bands ( Ladd’s bands )
      B)Intrinsic  Disorders --
           I) Inflamation//Infection-
               1) Postbulbar ulcer,
               2) crohn  disease,
               3) sprue,
               4) Tuberculosis,
               5) strongyloidiasis,
          II) Tumor – duodenal/ampullary malliganancy ,
    C)Diseases in adjacent structures
              1)Pancreatitis, Pseudocyst, Pancreatic carcinoma,
              2)Cholecystitis,
              3)Contiguous abscess,
              4)Metastasis to pancreaticoduodenal nodes, (lymphoma, lung cancer, breast cancer)
   D) Trauma,
              1)Duodenal rupture,
              2)Intramural haematoma,
   E) Vascular –
             1)Superior Mesentric Artery Syndrome,
             2)Aortico duodenal fistula,
            3)Preduodenal portal vein.