Wilke's Syndrome: A Missed Diagnosis in Pulmonary Tuberculosis in an Adolescent

Abstract

Background: Superior mesenteric artery (SMA) syndrome or Wilke's syndrome is a rare, atypical cause of upper gastrointestinal tract obstruction. It occurs due to acute angulation between SMA and aorta causing compression of the third part of the duodenum inbetween them leading to proximal intestinal obstruction. Clinical Description: SMA syndrome occurs mostly in patients who have significant weight loss. It occurs mostly due to the loss of the retroperitoneal fat pad, which serves as a cushion for the duodenum protecting it from compression between the two arteries. Causes include prolonged supine bed rest, spine surgery, an unusual high insertion of ligament of Treitz, other causes leading to weight loss, and congenital anatomical defects. Symptoms include weight loss, bilious vomiting, pain abdomen, postprandial nausea, early satiety, and anorexia. We report a 14-year-old female, a known case of pulmonary tuberculosis, who developed pneumothorax followed by acute gastric dilatation superadded with septicemia and upper gastrointestinal tract obstructive symptoms during the hospital course. Management: Detailed history and radio imaging such as barium studies or contrast-enhanced computerized tomography abdomen are required for diagnosis. Treatment includes conservative management such as gastric decompression, maintenance of electrolytes, nutritional rehabilitation via nasojejunal feeding, orally or parenterally. Treatment aims to restore the mesenteric fat pad to increases the angle between the two arteries. If it fails, surgery needs to be planned wherein duodenojejunostomy can be performed. Conclusion: An increased index of suspicion should be kept for this rare syndrome in children, especially in cases associated with significant weight loss. This may lead to timely diagnosis and saving a precious life.