Compression Of Duodenum Research Articles

S2886 Superior Mesenteric Artery Syndrome: Case Report and Review of Literature

INTRODUCTION: First reported by Rokitansky in 1861, Superior Mesenteric Artery (SMA) Syndrome is a rare medical condition occurring due to compression of third portion of duodenum between the SMA and abdominal aorta (AA).(1) It is often overlooked in medical practice. We describe the case of a 56-year-old F who had intermittent symptoms of nausea, vomiting and abdominal distention, who was found to have SMA syndrome. CASE DESCRIPTION/METHODS: A 56-year-old female was admitted to the hospital with abdominal distention, nausea, vomiting and fatigue. She had symptoms of abdominal distention and bloating for six years that required intermittent hospitalization and was managed conservatively with bowel rest and replenishment of electrolytes. She was cachectic with a BMI of 16 kg/m2. Abdomen was soft and distended with succession splash and normoactive bowel sounds. CT scan of the abdomen showed massively distended fluid filled stomach and narrow aortomesenteric angle (14°) (Figures 1A and 1B). EGD was performed which showed normal appearing patent pylorus and severe stenosis of the third portion of the duodenum with duodenal stenosis appearing to be secondary to extrinsic compression from the superior mesenteric artery (Figures 2A and 2B). She was started on small fractionated meals, low residue diet. Her hospital stay was complicated by sepsis, delirium and multiorgan failure. Due to her overall poor prognosis, she was discharged on hospice. DISCUSSION: The third portion of duodenum (D3) traverses in the area between the abdominal aorta and SMA at the level of L3 vertebra and is suspended at this location by the ligament of Treitz. This area decreases in people with rapid weight loss and cachexia. Symptoms include early satiety, bloating, nausea, intractable vomiting, acid reflux, weight loss, and post prandial upper abdominal pain. The diagnosis is confirmed by computerized tomogram (CT) angiogram of the abdomen demonstrating angle between the origin of the SMA and the AA to be < 22° and aortomesenteric distance less than 10 mm (normal 10–28 mm) (Figure 4). Conservative approach (gastric decompression and replenishment of fluids and electrolytes) is the first line strategy in management, followed by surgery (Duodenojejunostomy is gold standard).(2)Figure 1.: A- Normal appearing pylorus B- Compression of duodenum.Figure 2.: A- Distended stomach. B- narrow aortomesenteric angel and compression of duodenum.

A Case Series on Superior Mesenteric Artery Syndrome Surgical Management, Single Institution Experience.

Compression of duodenum by Superior Mesenteric Artery (SMA) causing proximal intestinal obstruction is an uncommon condition. Treatment of this condition involves conservative management initially followed by surgical management in those patients who have persistent symptoms. This case series evaluates surgical management and outcome of six patients after one year, who presented with SMA syndrome and describes a brief review of literature. Three patients underwent open duodenojejunostomy and the rest three underwent laparoscopic duodenojejunostomy. All patients had uneventful postoperative recovery. Postoperative requirement of analgesics was less in laparoscopic group versus open group. All the three patients in laparoscopic group could be mobilised out of bed on the day of the surgery itself. Mean duration of hospital stay was seven days for open surgery group and three days for the laparoscopy group. Outcome in terms of resolution of abdomen pain and vomiting was similar in both the groups. Four patients were asymptomatic after one year of follow up. A high index of clinical suspicion is needed for the diagnosis of SMA syndrome. Laparoscopic approach is feasible, safe, less morbid and effective as compared to open surgery. In the presence of facilities and surgical expertise, laparoscopic duodenojejunostomy should be considered the procedure of choice for SMA syndrome. Majority of patients remain symptom free at one year follow up.

Superior mesenteric artery syndrome as a postoperative complication following splenectomy: A case report and review

A 24-year-old male was brought to emergency department with blunt trauma abdomen. Ultrasound of the abdomen showed gross hemoperitoneum and splenic injury. Emergency laparotomy was done in view of hemodynamic instability and splenectomy was performed. Postoperatively patient had persistent vomiting. Upper gastrointestinal endoscopy revealed external compression of duodenum. Contrast-enhanced CT of the abdomen revealed acute angulation of superior mesenteric artery from aorta causing compression of third part of duodenum-diagnostic of superior mesenteric artery syndrome. Duodenojejunostomy was performed due to failure of conservative management. Postoperative period was uneventful and is on regular follow up.