Superior mesenteric artery syndrome

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Superior Mesenteric Artery Syndrome Abhilash

Transcript of Superior mesenteric artery syndrome

Page 1: Superior mesenteric artery syndrome

Superior Mesenteric Artery Syndrome

Abhilash

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• Von Rokitansky 1861.• Wilkie 1927.• 1960s – evidence to support the existence of

the syndrome• Incidence 0.1-0.3%.• More common in 10-30 years of age.• F>M• Only around 330 case reports in literature.

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Also called…

• Cast Syndrome• Wilkie Syndrome• Arteriomesenteric Duodenal Obstruction• Chronic Duodenal Ileus

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Anatomy

• Third portion of duodenum passes between the aorta and SMA around L3.

• Suspended in position by the ligament of Treitz• Typical angle created by these 2 vessels is 45-60

degrees. This angle is maintained by the mesenteric “fat pad”

• In SMA Syndrome this angle can be reduced to < 10%

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Risk Factors for developing SMA Syndrome

• Significant weight loss– Malignancy– Malabsorptive syndromes– Anorexia nervosa– Trauma– Wasting diseases• HIV, CHF, burns

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Risk Factors for developing SMA Syndrome

• Surgical correction of scoliosis• Congenitally short ligament of Treitz• Sudden gain in height. • Exaggerated lumbar lordosis.• RARE CASE REPORTS.– Pregnancy-gravid uterus reduces abdominal volume– Retroperitoneal hematoma following aneurysm repair– Prolonged bedrest– Strongyloides stercoralis infection.– Hyperthyroidism

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• Non- vascular theories for compression of 3rd part of duodenum.– Duodenal malrotation.– Inflammatory thickening of mesenteric root

secondary to acute pancreatitis.– Duodenal ulcer.– Bowel infarction.

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Clinical Manifestations

• Symptoms are consistent with small bowel obstruction

• Early Satiety• Postprandial epigastric pain• Nausea/Vomiting• Vomiting – bilious/partially digested.• May have distension, high pitched bowel sounds• Symptoms may be relieved by lying prone or on left

side

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Complications

• Electrolyte disturbances– Hypokalemia, metabolic alkalosis

• Gastric perforation• Gastric pneumatosis and portal venous gas• Obstructing duodenal bezoar

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Differential

• Post-op paralytic ileus• Duodenal dysmotility syndromes– Diabetes mellitus– Collagen vascular disease– Scleroderma– Chronic ideopathic intestinal pseudo-obstruction

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Diagnosis

• Diagnosis of exclusion.• A formal diagnosis is based on extrinsic

compression on duodenum between SMA and aorta, a distended duodenum and an aortomesenteric angle <20.

• Peristalsis should still be present

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Diagnosis

• KUB: gastric distension, dilation of proximal duodenum

• UGI: dilated stomach and proximal duodenum with retention of contrast, marked delay in passage of contrast from duodenum to distal small bowel

• CT/MRI: similar to UGI but also provides info about intra-abdominal fat concentration and other intra-abdominal pathology

• SMA arteriography: narrowing of the angle between SMA and aorta

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Treatment

• Correction of fluid and electrolyte imbalance• Decompression via NG tube• Nutrition– Orally– NJ feeds– TPN

• Metoclopramide iv

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Surgical options

• Duodenal mobilization and repositioning • Gastro-jejunostomy• Duodenojejunostomy

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Controversy

• Symptoms do not always correlate with radiography

• Follow up of 16 patients post op for SMA syndrome at 7 years showed correction of weight loss, decrease in vomiting but persistence of nausea, early satiety, fullness

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References1. Rev Esp Enferm Dig. 2013 Apr;105(4):236-238.2. Welsch T, Büchler MW, Kienle P. Recalling superior mesenteric artery syndrome. Dig Surg.

2007;24(3):149-56. Epub 2007 Apr 27.3. Cohen LB, Field SP, Sachar DB. The Superior Mesenteric Artery Syndrome. The Disease that

isn’t or is it? J Clin Gastroenterol 1985; 7(2):113-116.4. A. R. Ahmed and I. Taylor. Postgrad Med J 1997 73: 776-7785. Matheus et al. Syndrome of Duodenal Compression by the Superior Mesenteric Artery

Following Restorative Proctocolectomy: A Case Report and Review of Literature. Sao Paulo Med J 2005;123(3):151-3.

6. Simon M, Lemer MA. Duodenal compression by the mesenteric root in acute pancreatitis and inflammatory conditions of the bowel. Radiology 1962; 79: 75-80.

7. Ylinen P, Kinnunen J, Hockerstedt K. Superior Mesenteric Artery Syndrome. A Follow-up Study of 16 Operated Patients. J Clin Gastroenterol 1989; 11(4) 386-391.