Superior Mesenteric Artery Syndrome

BackgroundSuperior mesenteric artery (SMA) syndrome, also known as Wilkie's syndrome or Benign duodenal stasis, is a rare benign disease. It could threaten the life if the manifestation is severe and the treatment is inappropriate. In the patients with SMA syndrome, the third portion (transverse part) of the duodenum is compressed externally between the SMA and abdominal aorta (AA) leading to duodenal stasis and gastrointestinal obstruction. SMA syndrome may rarely combine with Nutcracker syndrome when left renal vein (LRV) was compressed between SMA and AA.Case presentationA 32-year-old female patient presented with complaints of gradually severe bloating, epigastric pain, left flank ache, nausea and occasional vomiting of 1 month's duration. The epigastric and left flank ache was aggravated when the patient was supine and relieved in a prone or left lateral decubitus. The abdominal bloating was associated with early satiety. The vomiting always started 40 min after meal. The patient gave a history of urine stone with drotaverine hydrochloride tablets treatment for two weeks before the gastrointestinal symptoms arising. The patient had no significant surgical history, but had a rapid weight loss of approximately 10 kg with a body mass index (BMI) from 21 kg/m2 to less than 18 kg/m2 over the last two months. An abdominal examination revealed upper abdominal tenderness and distention. The urine routine examination showed no significant abnormality. The findings of initial blood tests and other laboratory investigations were unremarkable.ConclusionsThis case reports a female patient with SMA syndrome with Nutcracker syndrome predisposed by Antispasmodics. We highlight the importance of the combination therapy of long-term nutritional supporting and prokinetic agents. Rehabilitating practice after discharge is beneficial to reduce recurrence.

ContextRestorative proctocolectomy with anastomosis of an ileal pouch to the anal canal is a new and rare cause for triggering the syndrome of duodenal compression by the superior mesenteric artery. Restorative proctocolectomy requires assessment of the position of the duodenum in relation to aortomesenteric constriction to avoid the occurrence of duodenal compression by the superior mesenteric artery.Case reportThe authors report on a case of this syndrome in a patient with familial adenomatous polyposis and review the literature on the etiopathogenesis, diagnosis, treatment and prevention of this unusual entity.

BackgroundThe duodenum and the left renal vein occupy the vascular angle made by the superior mesenteric artery and the aorta. When the angle becomes too acute, compression of either structure can occur. Each type of compression is associated with specific clinical symptoms that constitute a rare disorder. If clinical symptoms are mild, conservative treatment is implemented. However, surgery is often the only solution that can improve quality of life and/or avoid life-threatening complications. This report describes a case of a patient with both types of aortomesenteric compression that required two separate surgeries to alleviate all symptoms.Case presentationA 20-year-old white woman presented to the Emergency Room complaining of sudden onset severe left flank and lower left quadrant abdominal pain, nausea, and vomiting. A clinical work-up revealed elevated white blood cells and hematuria. She was discharged with a diagnosis of urinary tract infection. Symptoms continued to worsen over the subsequent 2 months. Repeated and extensive clinical work-ups failed to suggest evidence of serious pathology. Ultimately, an endoscopy revealed obstruction of her duodenum, and barium swallow identified compression by the superior mesenteric artery, leading to the diagnosis of superior mesenteric artery syndrome. She underwent a Roux-en-Y duodenojejunostomy. Six weeks later she continued to have severe left-sided pain and intermittent hematuria. Venography revealed compression of the left renal vein, extensive pelvic varices, and significant engorgement of her left ovarian vein. A diagnosis of nutcracker syndrome was made and a left renal vein transposition was performed. Significant improvement was seen after 8 weeks.ConclusionsThe disorders associated with aortomesenteric compression can lead to serious symptoms and sometimes death. Diagnosis is challenging not only because of the lack of awareness of these rare disorders, but also because they are associated with symptoms that are similar to those seen in less serious diseases. Guidance for health care professionals with respect to relevant radiological and clinical markers needs to be reconsidered in order to clarify the etiology of the diseases and create better diagnostic protocols.

BackgroundSuperior mesenteric artery syndrome is a rare form of duodenal obstruction that usually requires nonoperative management. While individual complications such as acute pancreatitis, portal venous gas, and gastric emphysema have been reported, the simultaneous occurrence of this triad in a single patient with superior mesenteric artery syndrome has never been documented. This case is novel as it highlights the successful nonoperative management of superior mesenteric artery syndrome despite the presence of these severe, potentially life-threatening complications.Case presentationA 26-year-old Asian male with a constitutional low body mass index of 14.53 kg/m2 presented with abrupt epigastric pain and bilious vomiting. Investigations revealed a diagnosis of superior mesenteric artery syndrome complicated by acute pancreatitis, portal venous gas, and gastric emphysema. The patient was treated nonoperatively with intensive care support, including nasogastric decompression and total parenteral nutrition. The interventions led to a significant reduction in gastric output, resolution of acute kidney injury and pain, and subsequent removal of the nasogastric tube. The patient was discharged well and showed no signs of obstruction at the 9-month follow-up, having gained weight.ConclusionsThis case demonstrates that the presence of portal venous gas and gastric emphysema in superior mesenteric artery syndrome, which typically raises suspicion for gastrointestinal necrosis, can be successfully managed conservatively if clinical signs of perforation or sepsis are absent. Clinicians should maintain a high index of suspicion for the complex presentations of superior mesenteric artery syndrome and prioritize aggressive nonoperative nutritional support, as it can resolve obstruction and preclude the need for surgery even in the setting of severe multi-systemic complications.