Arteriomesenteric occlusion of the duodenum: an entity?

Abstract

The syndrome caused by occlusion of the third portion of the duodenum by the superior arteriomesenteric vessels was launched by Rokitansky a century ago. It is fitting that the product of so illustrious a sponsor, in view of its many vagaries along the road of professional acceptance, be evaluated again as it begins its second century. According to who is consulted, it should be “relegated to history” or diagnosed much more often than it is. The sufferers from arteriomesenteric occlusion of the duodenum are commonly young, hyposthenic, lordotic females, often unmarried. It occurs with disturbing frequency in nurses and doctors' wives. This relationship to the medical profession might suggest more or less subtle pressures upon clinicians, radiologists, and surgeons to produce a socially and medically acceptable organic basis for the troubles that affect their own. The unmarried status of so many patients has been explained on the basis of the chronic disease making young women unsuitable candidates for the trials of marriage; I find it equally likely, however, that their unsuitability for these trials is just another manifestation of an unstable psychologic or neurovegetative constitution. The frequency and severity of “toxic” symptoms of headache and vertigo in the recorded examples of the syndrome, as contrasted with their absence in the truly organically determined aganglionosis of the duodenum, must lead us to doubt that patients with these complaints represent true examples of arteriomesenteric duodenal occlusion. Functional dilatation of the duodenum as a reflex from diseases in the gastrointestinal tract itself (especially peptic ulcer or gastritis), biliary tree, pancreas, and distant organs, is far commoner than dilatation from all the mechanical causes put together (bands, adhesions, intrinsic and extrinsic tumor, arteriomesenteric occlusion, etc.). Diminution in caliber of the duodenojejunal segment, and visible and palpable indentation of the superior mesenteric artery upon the anterior surface of the duodenum are normal findings. Obviously, this indentation becomes deeper, the more the duodenum becomes dilated. It is this mechanism, I believe, that has given rise to most of the diagnoses of arteriomesenteric occlusion made at the operating table; the role of the superior mesenteric artery is, in fact, circumstantial (circumstare, to stand around). This diagnosis cannot possibly be offered without radiologic support. Many of the radiologic observations in the proximal duodenum upon which the diagnosis has been made, however, such as vigorous to-and-fro peristalsis, delay and puddling of the barium especially in the supine hyposthenic patient, an apparently sharp cut-off or narrowing of the caliber a little to the right of the spine, regurgitation of barium into the stomach, all have been repeatedly shown to be normal findings.