A Case of Superior Mesenteric Artery Syndrome Secondary to Surreptitious Laxative Abuse

Abstract

Purpose: Superior mesenteric artery (SMA) syndrome is an uncommon and controversial entity which refers to compression of the third portion of the duodenum between the SMA and the aorta. This is typically due to loss of the intervening mesenteric fat pad from significant weight loss. Here, we present a case of a young woman who developed SMA syndrome after extensive weight loss from surreptitious laxative abuse. A 29 year old female with no significant past medical history was referred to Woman's and Infant's Hospital for evaluation of a one year history of abdominal pain, diarrhea and new onset weight loss. The patient had previously had a comprehensive workup which included multiple lab tests, upper and lower endoscopy, RUQ ultrasound, upper GI series with small bowel follow through, CT scan of abdomen and pelvis, hepatobiliary scan and ultimately, a diagnostic laparoscopy. Outside of a mildly elevated lipase, the patient had a completely normal workup. Upon presentation to our hospital, the patient was ill appearing and extremely cachectic with a BMI of 14. Outside records were obtained, and the patient provided the same history as previously reported. Additionally, the patient denied any current or previous use of laxatives. The patient underwent MR enterography upon admission which demonstrated a new proximal small bowel obstruction with a dilated stomach. Additionally, a laxative abuse screen was sent upon admission as well. A CT scan of the abdomen and pelvis was obtained to further evaluate the proximal small bowel and stomach. This too demonstrated the dilated small bowel and stomach with an approximate measurement of the angle between the SMA and aorta to be less than 10 degrees. This was consistent with a diagnosis of SMA syndrome. The patient ultimately underwent laproscopic duodenaljejunal bypass to alleviate the obstruction. One day after discharge, the patient's laxative abuse screen reported to be positive for bisacodyl in both her urine and feces. She continued to deny any current or previous laxative use.Figure