S2950 The Gutcracker: A Case of Superior Mesenteric Artery Syndrome

Abstract

Introduction: Superior Mesenteric Artery (SMA) Syndrome is estimated to effect 0.1-0.3% of the population and is not only a rare disease of exclusion but can be detrimental and debilitating making it challenging to treat. We describe a case of a patient with newly diagnosed SMA syndrome. Case Description/Methods: A 66-year-old male with a past medical history significant for congestive heart failure and Barrett’s esophagus presented with acute on chronic atypical chest pain and epigastric pain that has progressively worsened over three days. He described it as most severe after eating and felt that his entire chest and abdomen “was about to explode.” He reported decreased oral intake over the past 15 years due to the same chronic post-prandial epigastric pain. He reported a weight loss of 40-50 lbs. over the last year. He reported severe fatigue and has had trouble taking care of himself. The patient explained living in severe poverty without much of a support system. He also had nausea and decreased appetite with frequent belching. He was a cachectic appearing male with diffuse abdominal tenderness. A CT of the abdomen and pelvis was performed which demonstrated significant narrowing of the third portion of the duodenum at the level of SMA. Once a cardiac etiology of the pain was ruled out, an EGD was performed which discovered a significant amount of several days’ worth of undigested food content in the duodenum with duodenal narrowing. Since the CT and EGD findings were supportive of SMA syndrome, Surgery was consulted for potential surgical options. Surgery recommended an upper GI series to assess the motility and the patient was found to have transient vertical compression of the duodenum and delayed duodenal transit, confirming SMA syndrome. Discussion: Establishing the therapeutic approach was challenging as the patient was too frail to improve his diet on his own and too malnourished for surgical consideration. Conservative therapy with nutritional support was initiated and a multidisciplinary approach involving nutrition, speech pathology, and psychiatry was essential. Surgical management remained a potential option should conservative therapy fail. Due to his nausea, low appetite, and pain, he was started on TPN for further nutritional support. The case illustrates the complexity of SMA syndrome and the importance of a multidisciplinary approach to optimize treatment options and support the mental and physical wellbeing of the patient.Figure 1.: Upper GI Series revealing transient vertical compression of the duodenum and delayed duodenal transit consistent with SMA syndrome.