|Year : 2017 | Volume
| Issue : 1 | Page : 50-53
Superior mesenteric artery syndrome - A clinicoradiologic case report
Prashant Uddhaorao Titare, Bhawana D Sonawane, Pradip B Rathod, Narendra G Tembhekar
Department of Radiology, Government Medical College and Superspeciality Hospital, Nagpur, Maharashtra, India
|Date of Web Publication||14-Mar-2017|
Prashant Uddhaorao Titare
Department of Radiology, Government Medical College and Superspeciality Hospital, Near Tukdoji Square, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None
Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction due to compression of the third part of duodenum between SMA and aorta. Clinical suspicion and radiological findings are playing important role in the diagnosis of SMA syndrome. We report here the clinicoradiologic findings in a case of 66-year-old Indian male. In our case, abdominal aortic tortuosity in an elderly patient was the cause for SMA syndrome.
Keywords: Aortomesenteric angle, aortomesenteric distance, superior mesenteric artery syndrome
|How to cite this article:|
Titare PU, Sonawane BD, Rathod PB, Tembhekar NG. Superior mesenteric artery syndrome - A clinicoradiologic case report. J Mahatma Gandhi Inst Med Sci 2017;22:50-3
|How to cite this URL:|
Titare PU, Sonawane BD, Rathod PB, Tembhekar NG. Superior mesenteric artery syndrome - A clinicoradiologic case report. J Mahatma Gandhi Inst Med Sci [serial online] 2017 [cited 2023 Mar 30];22:50-3. Available from: https://www.jmgims.co.in/text.asp?2017/22/1/50/202019
| Introduction|| |
Superior mesenteric artery (SMA) syndrome is a rare cause of upper gastrointestinal tract obstruction characterized by the compression of the third part of duodenum (D3) between SMA and aorta. It is also known by various names like Wilkie syndrome, Cast syndrome, arteriomesenteric duodenal compression, and chronic duodenal ileus., Incidence of the SMA syndrome varies from 0.2% to 0.78% in the barium series of the upper gastrointestinal tract.,, High index of clinical suspicion and radiological findings plays important role in the diagnosis of this syndrome.
| Case Report|| |
A 66-year-old Indian male presented to our hospital with prolonged history of recurrent abdominal pain and vomiting. There was history of symptomatic relief in prone position. Significant weight loss was present in past 1-year. He was previously hospitalized multiple times for similar complaints. Hematemesis was absent. He did not complain of any respiratory, neurological, cardiac, and urological symptom.
On general examination his vitals were stable. Abdominal examination revealed epigastric fullness. Cardiac, respiratory, and neurological examination was normal. Routine blood and urine investigation were within normal limits. Plain erect abdominal radiograph and chest radiograph was normal. Upper gastrointestinal endoscopy revealed changes of esophagitis in the distal esophagus and luminal narrowing at the third part of duodenum without any intrinsic abnormality.
Upper gastrointestinal barium study [Figure 1] revealed dilated stomach, first (D1) and second (D2) part of duodenum with a significant luminal narrowing at the third part of duodenum without any intrinsic mucosal abnormality. Distal bowel loops were opacified with barium. Ultrasonography [Figure 2] and [Figure 3] showed narrowed angle (17°) and short distance (5 mm) between SMA and aorta causing compression of the third part of duodenum resulting in proximal duodenal dilatation. Then contrast-enhanced computed tomography (CECT) was advised for confirmation. CECT [Figure 4] and [Figure 5] revealed reduced aortomesenteric angle (16°) and short aortomesenteric distance (4.8 mm). Compression was seen at D3 level with dilatation of stomach and proximal duodenum (D1 and D2). Additional finding of abdominal aortic tortuosity was noted [Figure 6].
|Figure 1: Upper gastrointestinal fluoroscopic oblique barium image showing dilatation of stomach (S) and proximal part duodenum (D)|
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|Figure 2: Ultrasound image (in sagittal plane) showing narrowing of the angle between superior mesenteric artery (SMA) and AORTA|
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|Figure 3: Ultrasound image (in transverse plane) showing narrowing of the distance between superior mesenteric artery (SMA) (S) and aorta (AO). Compressed third part of duodenum (arrow) seen between the SMA and aorta with dilatation of proximal part of duodenum (D)|
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|Figure 4: Contrast-enhanced sagittal computed tomography image showing narrowing of the angle between superior mesenteric artery (black arrow) and aorta (gray arrow)|
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|Figure 5: Contrast-enhanced axial computed tomography image showing narrowing of the distance between superior mesenteric artery (S) and aorta (A) causing compression of the third part of duodenum between superior mesenteric artery and aorta with dilatation of proximal part of duodenum (D)|
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|Figure 6: Contrast-enhanced computed tomography (arterial phase) sequential coronal images of abdominal aorta showing tortuous course of abdominal aorta|
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On the basis of clinical and imaging findings, a diagnosis of SMA syndrome was suggested. Initial conservative approach was tried with nasogastric drainage, fluid electrolyte therapy, and small frequent meals, but because of its failure the patient was managed by duodenojejunostomy. At present our patient is symptom-free.
| Discussion|| |
Earliest description of the SMA syndrome was given by Rokitansky. Later on Wilkie provided a more detailed anatomical, clinical, and pathophysiological aspect of this syndrome.
In humans, SMA leaves the aorta at an acute downward angle. This results in the formation of vascular angle between aorta and SMA through which the third part of duodenum passes. Normally, fat and lymphatic's maintains this angle. Normal aortomesenteric distance and aortomesenteric angle is 10–28 mm and 25–60,° respectively. In SMA syndrome aortomesenteric angle narrowed to 7–22° and aortomesenteric distance reduced to 2–8 mm., Cut-off values were reported to be 22° for aortomesenteric angle (42% sensitivity and 100% specificity) and 8 mm for aortomesenteric distance (100% sensitivity and specificity). In our case, CT and ultrasound measurement of aortomesenteric angle and aortomesenteric distance is less than cut off value.
There are multiple causes for SMA syndrome like severe cachexia or catabolic state due to neoplasm, anorexia nervosa, severe head injury or burn, prolonged bed rest, bariatric surgery, Nissan fundoplication, spinal scoliosis surgery, spinal deformity, high insertion of ligament of treitz, intestinal malrotation, peritoneal adhesions, low origin of SMA, and elderly patient with heavily calcified or tortuous aorta. Elderly patient with reduced retroperitoneal fat and abdominal aortic tortuosity was the cause of SMA syndrome in our case.
The most common symptom in SMA syndrome is intermittent abdominal (epigastric) pain and vomiting. Nausea and vomiting may result in anorexia and weight loss. Early satiety, eructations and few times subacute small bowel obstruction also have been reported. The symptoms are relieved in left lateral decubitus, prone or knee to chest position. Similar common complaints and relieving factor was present in our case. Duodenal and gastric dilatation may lead to aspiration pneumonia and acute gastric rupture. These complications were not seen in our case. Succussion splash may be seen on abdominal examination. Peptic ulcer disease and hyperchlorhydria may occur in some cases. Only esophagitis in the distal esophagus was present in our case.
Traditionally, upper gastrointestinal barium study was used for the diagnosis of SMA syndrome. Gastro-duodenal dilatation, retention of barium in the proximal duodenum, and characteristic vertical linear extrinsic impression in the third part of duodenum are the findings seen on barium study but they are nonspecific for the SMA syndrome. Earlier angiographic measurement of the aortomesenteric angle was thought to be a gold standard. Now-a-day's noninvasive modalities like ultrasonography, CT or magnetic resonance angiography are useful for the diagnosis of SMA syndrome. CT is superior to ultrasound because it can measure the aortomesenteric angle and demonstrate the gastro-duodenal dilatation at the same time., In our case, obstruction was demonstrated at the third portion of duodenum on barium, ultrasound, and CT, but aortomesenteric angle and aortomesenteric distance were well demonstrable on CT and ultrasound. Barium study showed opacification of distal loops suggesting the partial nature of duodenal obstruction.
Initial treatment is usually conservative in the form of nasogastric drainage, mobilization into prone or left lateral decubitus position, correction of fluid-electrolyte imbalance. Small frequent meals, nasojejunal tube feeding, and total parenteral nutrition are the ways of feeding shown to be effective in SMA syndrome. Aim was to increase the retroperitoneal fat so that aortomesenteric angle is corrected. Surgical treatment is indicated when conservative treatment fails or in cases of progressive severe weight loss, pronounced duodenal dilatation with stasis, and complicated peptic ulcer. Surgical procedures like gastroduodenostomy, strong's operation (duodenal mobilization for lowering duodenojejunal flexure) and duodenojejunostomy are used to treat this syndrome. Duodenojejunostomy is reported to be the treatment of choice with a success rate of 90%. Our patient did not respond to the conservative treatment hence duodenojejunostomy was done.
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