3216 SMA Syndrome and Small Bowel Obstruction

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INTRODUCTION: Superior mesenteric artery (SMA) syndrome is a condition in which the third portion of the duodenum, between the abdominal aorta and SMA, is compressed. The disease is rare, as incidence rates range from 0.1% to 0.3%. It is more prevalent in females aged 10 to 39 years old. Symptoms include severe weight loss, epigastric pain, nausea, and vomiting. SMA syndrome is an uncommon cause of small bowel obstruction (SBO). This case describes a patient with known SMA syndrome who presented with acute symptoms of SBO. CASE DESCRIPTION/METHODS: A 36-year-old male with past medical history of polysubstance abuse, hypertension, GERD, psychiatric disorders (bipolar, anxiety, depression), GI bleeds, and SMA syndrome presented with worsening abdominal pain for two weeks. Pain was described as dull and constant with radiation to his lower back. Associated symptoms included worsening nausea and coffee ground hematemesis, as well as dark stools and decreased appetite. The patient was hemodynamically stable. NG tube was placed to help with decompression. He was given IV fluids and started on pantoprazole 40 mg BID IV. CT abdomen with contrast showed a 4 mm obstruction at the third portion of the duodenum consistent with SMA syndrome and a second jejunal area of transition. General surgery deemed him to not be an appropriate surgical candidate, and medical management was recommended. EGD demonstrated a collapse of the duodenal mucosa at the third to fourth portion of the duodenum with moderate chronic appearing dilation of the duodenum proximal to this area. A small sliding hiatal hernia and LA class D esophagitis were also seen. He was started on sucralfate 1 gm QID PO and switched to pantoprazole 40 mg daily PO upon discharge. Liquid diet was advanced as tolerated. Once his symptoms improved, he was discharged and instructed to follow up with a GI physician. DISCUSSION: SMA syndrome should be considered in the differential for young adults presenting with symptoms of SBO due to the morbidity and mortality associated with malnutrition, dehydration, and other complications, such as gastric perforation and hemorrhage. Diagnosis is made based on clinical symptoms and radiologic imaging. Initial treatment is non-operative medical management with fluid resuscitation, TPN, NG tube, and electrolyte correction. Laparoscopic duodenojejunostomy is the most common surgical intervention used when medical management fails. In this case, the patient was able to have improvement in symptoms with medical management alone.