Superior Mesenteric Artery Syndrome as a Presenting Sign of Inflammatory Bowel Disease.

Abstract

To the Editor: We would like to inform the readers of a unique presentation of inflammatory bowel disease. We evaluated a 17-year-old girl who originally presented to her primary care provider with chronic abdominal pain that progressed to oral intolerance and vomiting. A computed tomography scan and UGI study (1,2) had findings consistent with superior mesenteric artery (SMA) syndrome, with no other abnormalities of the small or large bowel. On admission, a nasoduodenal tube was placed, but the patient was unable to tolerate feedings. Because the patient had no reason for SMA syndrome, such as surgery or weight loss, an upper endoscopy was performed and showed significant inflammation in the bulb and the second part of the duodenum with luminal narrowing (2). Biopsies revealed pan-duodenitis with chronic inflammation, with negative Helicobacter pylori urease testing. Subsequent colonoscopy noted minimal gross findings, but biopsies showed patchy ileitis with focal cryptitis. The patient was treated with TPN and IV corticosteroids for presumed Crohn disease (CD) and demonstrated clinical response. Follow-up magnetic resonance enterography on adalimumab was normal (Figs. 1 and 2).FIGURE 1: UGI: dilated second portion of the duodenum with suggestion of vertical extrinsic compression from superior mesenteric artery. There are associated thickened mucosal folds (yellow arrow). Coronal plane computed tomography (CT): dilated proximal duodenum (blue arrow) and decompressed jejunum (red arrow).FIGURE 2: Endoscopy: duodenitis. Computed tomography (CT): dilated second portion of duodenum with thickened bowel wall (blue arrow). Superior mesenteric artery (red arrow).SMA syndrome is seen in patients with surgery and subsequent altered anatomy or severe and rapid weight loss (1). No correlation between CD and SMA syndrome has been established, but SMA syndrome with or after diagnosis of inflammatory bowel disease due to weight loss is previously reported (1,2). In this case, the diseased portions of the duodenum (first and second) combined with a relatively decompressed third portion led to the appearance and diagnosis of SMA syndrome, but instead was a presenting sign of CD.