Intermittent arteriomesenteric occlusion of the duodenum.

Abstract

Some thirty-five years ago, arteriomesenteric occlusion of the duodenum was in great vogue medically and was a popular subject in medical writing. It appeared under various names, such as superior mesenteric artery syndrome, intermittent arteriomesenteric occlusion of the duodenum, duodenal regurgitation, chronic duodenal ileus, and frequently under the general term duodenal stasis. Although the diagnosis is essentially a radiological problem, it occupies a very insignificant place in recent radiological literature and in the textbooks. It is our belief that intermittent arteriomesenteric occlusion of the duodenum is somewhat more common than is generally appreciated and that the possibility of its existence is not given proper consideration by most clinicians and radiologists, since it appears to be rather rarely recognized. Inasmuch as the condition is so readily overlooked and patients suffering from it are so often abandoned as neurotics, we feel that a review of the subject is warranted. Duodenal stasis may be divided into two major groups: (a) chronic obstruction due to organic disease, as congenital bands, adhesions, malrotation of the intestine, neoplasm, etc., and (b) intermittent obstruction, mechanical in nature, due to compression of the terminal duodenum by the mesentery and its contents. Our consideration will be confined entirely to occlusion caused by arteriomesenteric compression of the duodenum, a condition characterized by intermittent interference with the passage of the gastroduodenal contents through the third portion of the duodenum. The nature of this syndrome will be better comprehended if the anatomy of the transverse duodenum and its relationships are reviewed. The third portion of the duodenum, as it crosses the spine, is fixed in a compartment bounded posteriorly by the spine and the aorta, and anteriorly by the root of the mesentery containing the superior mesenteric artery, vein, and nerve (Fig. 1). Being so contained, it is affected by any process which encroaches upon this space. Thus increased lordosis of the spine diminishes the space posteriorly, and a short mesentery, marked loss of weight, and a redundant relaxed abdominal wall increase the dragging effect of the mesenteric root and consequently narrow the space anteriorly (1–9). The intermittent character of the condition and the precipitation of the attacks by fatigue and by nervous strain indicate that neuromuscular derangement is also an important etiologic factor (10). The condition occurs most commonly in asthenic patients of a lean, slender habitus and is much more common in females than in males (8, 11, 12, 13). The intermittent symptoms may date from childhood, but they more frequently develop in middle age (8, 14). Chronic illness, sudden loss of weight, periods of mental worry, conditions leading to relaxation of the abdominal wall (such as multiple pregnancies) are all precipitating factors.