A Case of Thrombosed Inferior Mesenteric Artery Aneurysm ...
Superior mesenteric artery syndrome
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Transcript of Superior mesenteric artery syndrome
Superior Mesenteric Artery Syndrome
Abhilash
• 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.
Also called…
• Cast Syndrome• Wilkie Syndrome• Arteriomesenteric Duodenal Obstruction• Chronic Duodenal Ileus
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%
Risk Factors for developing SMA Syndrome
• Significant weight loss– Malignancy– Malabsorptive syndromes– Anorexia nervosa– Trauma– Wasting diseases• HIV, CHF, burns
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
• 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.
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
Complications
• Electrolyte disturbances– Hypokalemia, metabolic alkalosis
• Gastric perforation• Gastric pneumatosis and portal venous gas• Obstructing duodenal bezoar
Differential
• Post-op paralytic ileus• Duodenal dysmotility syndromes– Diabetes mellitus– Collagen vascular disease– Scleroderma– Chronic ideopathic intestinal pseudo-obstruction
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
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
Treatment
• Correction of fluid and electrolyte imbalance• Decompression via NG tube• Nutrition– Orally– NJ feeds– TPN
• Metoclopramide iv
Surgical options
• Duodenal mobilization and repositioning • Gastro-jejunostomy• Duodenojejunostomy
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
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.