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Superior mesenteric artery syndrome caused by weight loss in a malnourished Syrian man

Superior mesenteric artery syndrome caused by weight loss in a malnourished Syrian man Superior mesenteric artery syndrome is a rare cause of upper gastrointestinal obstruction in which the third part of the duodenum is compressed between the superior mesenteric artery and the abdominal aorta, and the compression of the duodenum is caused by a narrowed aortomesenteric angle. We report in this case a 35-year-old patient who came with features of small bowel obstruction, weight loss and had a history of malnutrition because of war. Multi-slice computerized tomography showed a narrowed aortomesenteric angle and distance. Conservative treatment was presented and, after 3 months of observation, the patient gained weight. Key words: superior mesenteric artery syndrome; aortomesenteric angle; upper gastrointestinal obstruction; malnutrition patient with SMA syndrome (written informed consent was Introduction obtained from the patient), aiming to draw doctors’ attention to it, Superior mesenteric artery (SMA) syndrome is one of the rare and to include it in the differential diagnosis of proximal intestinal causes of small bowel obstruction [1]. The defining feature of this obstruction symptoms. In addition, it should be considered as a syndrome is the compression of the third part of the duodenum complication of malnutrition and starvation experienced in wars due to narrowing of the space between the SMA and the abdomi- and catastrophes, and so should be kept in the minds of health nal aorta leading to upper gastrointestinal obstruction [2]. The workers in such situations. true incidence of this syndrome is unknown, but it has been esti- mated to be approximately 0.013–0.3% [3]. Catabolic states and malnutrition as in this case may predispose to this condition by a Case presentation reductioninretroperitoneal fattissue. SMA syndrome can present A 35-year-old Caucasian man presented to the Gastroenterology itself as acute small bowel obstruction or as intermittent compres- sion with chronic symptoms. The classical presentation is recur- Department at Aleppo University Hospital with postprandial rent postprandial pain, nausea, vomiting, bloating, abdominal non-projectile vomiting that started 2 months earlier with no discomfort or pain and tenderness. In this case, we present a abdominal pain. As a history, he had experienced excessive Submitted: 27 October 2017; Revised: 30 November 2017; Accepted: 8 December 2017 V C The Author(s) 2018. Published by Oxford University Press and Sixth Affiliated Hospital of Sun Yat-sen University This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 223 Downloaded from https://academic.oup.com/gastro/article-abstract/7/3/223/4819229 by Ed 'DeepDyve' Gillespie user on 18 June 2019 224 | Z. Aljarad et al. Figure 1. Sagittal multi-slice computerized tomography (CT) image showing a reduced angle (14.6 ) and decreased distance (3.9 mm) between the superior mesenteric artery and abdominal aorta. weight loss because of hunger and malnutrition caused by the loss, which leads to the loss of retroperitoneal fat [5]. Our difficult humanitarian situation related to Syrian war, leading to patient suffered from severe weight loss because of hunger and weight loss within 5 months from 135 kg (body mass index [BMI]: malnutrition caused by the difficult humanitarian situation due 2 2 42.61 kg/m ) to 100 kg (BMI: 31.56 kg/m ) before the chief com- to Syrian war, which made him lose 35 kg (first phase of weight plaint started. After the vomiting problem described above began, loss due to hunger). SMA syndrome is most commonly associated with severe, he lost an additional 40 kg, weighing 60 kg (BMI: 18.94 kg/m )over 4 months. He had no other comorbidities. His abdomen was soft debilitating illnesses, such as malignancy, malabsorption syn- dromes, AIDS, trauma and burns [5]. Weight loss is not the only and not distended, and vital signs and review of other systems were normal. Laboratory findings revealed a mild decrease in factor responsible for SMA syndrome: surgical intervention that distorts the anatomy can also lead to it. Corrective spinal sur- serum albumin and a mild elevation in aspartate transaminase (AST) and alanine aminotransferase (ALT). The echography of the gery for scoliosis and esophagoectomy on some occasions are among the causes. Moreover, congenital short ligament of abdomen had not revealed any problems. On endoscopy, no gas- tric outlet obstruction or other abnormalities had been found. Treitz suspending the duodenum in an abnormally cephalic When we reached the end of the second part of the duodenum, position has also been reported in the literature as one of the we pumped air to show the third part. A narrowing in the third causes [5]. Females aged between 10 and 40 years are more com- part of the duodenum was detected. The mucosa of the stomach monly affected [7]. The predominant clinical symptoms that and duodenum was normal, and no inflammatory changes were patients show with vascular compression of the duodenum are noticed. Multi-slice computerized tomography (MSCT) showed nausea, vomiting and postprandial abdominal pain centered at compression of the third part of the duodenum between the the epigastrium. Our patient complained of postprandial vomit- aorta and the SMA due to decreased distance (3.9 mm) and nar- ing without abdominal pain. These symptoms can be episodic rowed angle (14.6 ) between these two arteries (Figure 1). A diag- or persistent and, if persistent as in our case, malnourishment nosis of SMA syndrome was made. A conservative therapy of is common, due to narrowing of the duodenal lumen and the high-calorie diet was applied through a nasojejunal tube. The resulting vomiting, which made the patient lose an additional patient started gaining weight fast and postprandial vomiting 40 kg (second phase of weight loss). was disappearing gradually. After 7 days, the nasojejunal tube Patients with a history of symptoms suggesting SMA syn- was removed completely and the patient tolerated an oral diet, drome should undergo further radiographic studies to establish and was discharged. During the follow-up of 3 months, the the diagnosis. Upper gastrointestinal series, MCST scan or CT patient had no complaints and weighed 80 kg (BMI 25.25kg/m ). angiography, magnetic resonance angiography, conventional angiography, ultrasonography and endoscopy had all been used for diagnosis [8]. Endoscopy was performed to exclude pyloric Discussion stenosis, but we noticed narrowing in the third part of the duo- SMA syndrome is a relatively rare clinical condition as a cause denum. Diagnosis was confirmed by MSCT, which showed com- of small bowel obstruction. It was first described by Rokitansky pression of the third part of the duodenum between the aorta in 1842. Wilkie published the first series in 1927; therefore, SMA and the SMA due to decreased distance (3.9 mm) and narrowed syndrome is also called Wilkie’s syndrome [4]. SMA syndrome is angle (14.6 ) between these two arteries. characterized by a compression of the third portion of the duo- Therapeutic options for SMA syndrome are conservative denum due to narrowing of the space between the SMA and management or surgical bypass of the obstruction. The goal of aorta. It is primarily attributed to loss of the intervening mesen- medical therapy is to induce weight gain, which would presum- teric fat pad [5]. Diagnosis is confirmed by the loss of an angle ably result in an increase in fat at the mesenteric root. Enteral between the SMA and the abdominal aorta to less than 20 . The nutrition can be provided using a nasoenteric feeding tube posi- distance between the two vessels is also decreased to less than tioned distal to the ligament of Treitz. We applied a nutritional 6 mm (the normal distance is 8–12 mm) [6]. Aortomesenteric support as a first line therapy through a nasojejunal tube and angle and distance in our case were 14.6 and 3.99 mm, respec- the patient started gaining weight and postprandial vomiting tively. Several factors are listed that have an effect on the aorto- began to disappear gradually. Failure of the treatment, although mesenteric angle. The most common one is significant weight a certain period of time cannot be determined, is to be detected Downloaded from https://academic.oup.com/gastro/article-abstract/7/3/223/4819229 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Superior mesenteric artery syndrome and malnutrition | 225 2. Su MC, Lee CH, Wange CC. Education and imaging: gastroin- through the presence of vomiting as the chief symptom and recurrence of the other symptoms. It also indicates the need for testinal: superior mesenteric artery syndrome initially surgical treatment for SMA syndrome. If conservative treatment presenting like reflux esophagitis. J Gastroenterol Hepatol 2010; fails, surgical treatment can be performed. A duodenojejunos- 25:645. tomy remains the operation of choice to relieve the obstruction, 3. Ylinen P, Kinnunen J, Hockerstedt K. Superior mesenteric with success rates of up to 90% [3]. In our case, however, the artery syndrome: a follow-up study of 16 operated patients. patient responded very well to conservative therapy and there J Clin Gastroenterol 1989;11:386–91. was no need for surgical intervention. 4. Wilkie DP. Chronic duodenal ileus. Am J Med Sci 1927;173: 643–9. 5. Scovell S, Hamdan A. Superior mesenteric artery syndrome. Conflict of interest www.uptodate.com (9 January 2018, date last accessed). None declared. 6. Derrick JR, Fadhli HA. Surgical anatomy of the superior mesen- teric artery. Am Surg 1965;31:545–7. 7. Zaraket V, Deeb L. Wilkie’s syndrome or superior mesenteric References artery syndrome: fact or fantasy? Case Rep Gastroenterol 2015;9: 1. Agha RA, Fowler AJ, Saetta A et al., the SCARE Group. 194–9. The SCARE statement: consensus-based surgical case report 8. Welsch T, Bu ¨ chler MW, Kienle P. Recalling superior mesenteric guidelines. Int J Surg 2016;34:180–6. artery syndrome. Dig Surg 2017;24:149–56. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Gastroenterology Report Oxford University Press

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Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press and Sixth Affiliated Hospital of Sun Yat-sen University
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2052-0034
DOI
10.1093/gastro/gox045
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Abstract

Superior mesenteric artery syndrome is a rare cause of upper gastrointestinal obstruction in which the third part of the duodenum is compressed between the superior mesenteric artery and the abdominal aorta, and the compression of the duodenum is caused by a narrowed aortomesenteric angle. We report in this case a 35-year-old patient who came with features of small bowel obstruction, weight loss and had a history of malnutrition because of war. Multi-slice computerized tomography showed a narrowed aortomesenteric angle and distance. Conservative treatment was presented and, after 3 months of observation, the patient gained weight. Key words: superior mesenteric artery syndrome; aortomesenteric angle; upper gastrointestinal obstruction; malnutrition patient with SMA syndrome (written informed consent was Introduction obtained from the patient), aiming to draw doctors’ attention to it, Superior mesenteric artery (SMA) syndrome is one of the rare and to include it in the differential diagnosis of proximal intestinal causes of small bowel obstruction [1]. The defining feature of this obstruction symptoms. In addition, it should be considered as a syndrome is the compression of the third part of the duodenum complication of malnutrition and starvation experienced in wars due to narrowing of the space between the SMA and the abdomi- and catastrophes, and so should be kept in the minds of health nal aorta leading to upper gastrointestinal obstruction [2]. The workers in such situations. true incidence of this syndrome is unknown, but it has been esti- mated to be approximately 0.013–0.3% [3]. Catabolic states and malnutrition as in this case may predispose to this condition by a Case presentation reductioninretroperitoneal fattissue. SMA syndrome can present A 35-year-old Caucasian man presented to the Gastroenterology itself as acute small bowel obstruction or as intermittent compres- sion with chronic symptoms. The classical presentation is recur- Department at Aleppo University Hospital with postprandial rent postprandial pain, nausea, vomiting, bloating, abdominal non-projectile vomiting that started 2 months earlier with no discomfort or pain and tenderness. In this case, we present a abdominal pain. As a history, he had experienced excessive Submitted: 27 October 2017; Revised: 30 November 2017; Accepted: 8 December 2017 V C The Author(s) 2018. Published by Oxford University Press and Sixth Affiliated Hospital of Sun Yat-sen University This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 223 Downloaded from https://academic.oup.com/gastro/article-abstract/7/3/223/4819229 by Ed 'DeepDyve' Gillespie user on 18 June 2019 224 | Z. Aljarad et al. Figure 1. Sagittal multi-slice computerized tomography (CT) image showing a reduced angle (14.6 ) and decreased distance (3.9 mm) between the superior mesenteric artery and abdominal aorta. weight loss because of hunger and malnutrition caused by the loss, which leads to the loss of retroperitoneal fat [5]. Our difficult humanitarian situation related to Syrian war, leading to patient suffered from severe weight loss because of hunger and weight loss within 5 months from 135 kg (body mass index [BMI]: malnutrition caused by the difficult humanitarian situation due 2 2 42.61 kg/m ) to 100 kg (BMI: 31.56 kg/m ) before the chief com- to Syrian war, which made him lose 35 kg (first phase of weight plaint started. After the vomiting problem described above began, loss due to hunger). SMA syndrome is most commonly associated with severe, he lost an additional 40 kg, weighing 60 kg (BMI: 18.94 kg/m )over 4 months. He had no other comorbidities. His abdomen was soft debilitating illnesses, such as malignancy, malabsorption syn- dromes, AIDS, trauma and burns [5]. Weight loss is not the only and not distended, and vital signs and review of other systems were normal. Laboratory findings revealed a mild decrease in factor responsible for SMA syndrome: surgical intervention that distorts the anatomy can also lead to it. Corrective spinal sur- serum albumin and a mild elevation in aspartate transaminase (AST) and alanine aminotransferase (ALT). The echography of the gery for scoliosis and esophagoectomy on some occasions are among the causes. Moreover, congenital short ligament of abdomen had not revealed any problems. On endoscopy, no gas- tric outlet obstruction or other abnormalities had been found. Treitz suspending the duodenum in an abnormally cephalic When we reached the end of the second part of the duodenum, position has also been reported in the literature as one of the we pumped air to show the third part. A narrowing in the third causes [5]. Females aged between 10 and 40 years are more com- part of the duodenum was detected. The mucosa of the stomach monly affected [7]. The predominant clinical symptoms that and duodenum was normal, and no inflammatory changes were patients show with vascular compression of the duodenum are noticed. Multi-slice computerized tomography (MSCT) showed nausea, vomiting and postprandial abdominal pain centered at compression of the third part of the duodenum between the the epigastrium. Our patient complained of postprandial vomit- aorta and the SMA due to decreased distance (3.9 mm) and nar- ing without abdominal pain. These symptoms can be episodic rowed angle (14.6 ) between these two arteries (Figure 1). A diag- or persistent and, if persistent as in our case, malnourishment nosis of SMA syndrome was made. A conservative therapy of is common, due to narrowing of the duodenal lumen and the high-calorie diet was applied through a nasojejunal tube. The resulting vomiting, which made the patient lose an additional patient started gaining weight fast and postprandial vomiting 40 kg (second phase of weight loss). was disappearing gradually. After 7 days, the nasojejunal tube Patients with a history of symptoms suggesting SMA syn- was removed completely and the patient tolerated an oral diet, drome should undergo further radiographic studies to establish and was discharged. During the follow-up of 3 months, the the diagnosis. Upper gastrointestinal series, MCST scan or CT patient had no complaints and weighed 80 kg (BMI 25.25kg/m ). angiography, magnetic resonance angiography, conventional angiography, ultrasonography and endoscopy had all been used for diagnosis [8]. Endoscopy was performed to exclude pyloric Discussion stenosis, but we noticed narrowing in the third part of the duo- SMA syndrome is a relatively rare clinical condition as a cause denum. Diagnosis was confirmed by MSCT, which showed com- of small bowel obstruction. It was first described by Rokitansky pression of the third part of the duodenum between the aorta in 1842. Wilkie published the first series in 1927; therefore, SMA and the SMA due to decreased distance (3.9 mm) and narrowed syndrome is also called Wilkie’s syndrome [4]. SMA syndrome is angle (14.6 ) between these two arteries. characterized by a compression of the third portion of the duo- Therapeutic options for SMA syndrome are conservative denum due to narrowing of the space between the SMA and management or surgical bypass of the obstruction. The goal of aorta. It is primarily attributed to loss of the intervening mesen- medical therapy is to induce weight gain, which would presum- teric fat pad [5]. Diagnosis is confirmed by the loss of an angle ably result in an increase in fat at the mesenteric root. Enteral between the SMA and the abdominal aorta to less than 20 . The nutrition can be provided using a nasoenteric feeding tube posi- distance between the two vessels is also decreased to less than tioned distal to the ligament of Treitz. We applied a nutritional 6 mm (the normal distance is 8–12 mm) [6]. Aortomesenteric support as a first line therapy through a nasojejunal tube and angle and distance in our case were 14.6 and 3.99 mm, respec- the patient started gaining weight and postprandial vomiting tively. Several factors are listed that have an effect on the aorto- began to disappear gradually. Failure of the treatment, although mesenteric angle. The most common one is significant weight a certain period of time cannot be determined, is to be detected Downloaded from https://academic.oup.com/gastro/article-abstract/7/3/223/4819229 by Ed 'DeepDyve' Gillespie user on 18 June 2019 Superior mesenteric artery syndrome and malnutrition | 225 2. Su MC, Lee CH, Wange CC. Education and imaging: gastroin- through the presence of vomiting as the chief symptom and recurrence of the other symptoms. It also indicates the need for testinal: superior mesenteric artery syndrome initially surgical treatment for SMA syndrome. If conservative treatment presenting like reflux esophagitis. J Gastroenterol Hepatol 2010; fails, surgical treatment can be performed. A duodenojejunos- 25:645. tomy remains the operation of choice to relieve the obstruction, 3. Ylinen P, Kinnunen J, Hockerstedt K. Superior mesenteric with success rates of up to 90% [3]. In our case, however, the artery syndrome: a follow-up study of 16 operated patients. patient responded very well to conservative therapy and there J Clin Gastroenterol 1989;11:386–91. was no need for surgical intervention. 4. Wilkie DP. Chronic duodenal ileus. Am J Med Sci 1927;173: 643–9. 5. Scovell S, Hamdan A. Superior mesenteric artery syndrome. Conflict of interest www.uptodate.com (9 January 2018, date last accessed). None declared. 6. Derrick JR, Fadhli HA. Surgical anatomy of the superior mesen- teric artery. Am Surg 1965;31:545–7. 7. Zaraket V, Deeb L. Wilkie’s syndrome or superior mesenteric References artery syndrome: fact or fantasy? Case Rep Gastroenterol 2015;9: 1. Agha RA, Fowler AJ, Saetta A et al., the SCARE Group. 194–9. The SCARE statement: consensus-based surgical case report 8. Welsch T, Bu ¨ chler MW, Kienle P. Recalling superior mesenteric guidelines. Int J Surg 2016;34:180–6. artery syndrome. Dig Surg 2017;24:149–56.

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Gastroenterology ReportOxford University Press

Published: Jun 1, 2019

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