Superior Mesenteric Artery Syndrome Research Articles

Gastric Necrosis Caused by Acute Gastric Dilatation due to Superior Mesenteric Artery Syndrome—Report of a Case—

Gastric Necrosis Caused by Acute Gastric Dilatation due to Superior Mesenteric Artery Syndrome—Report of a Case—

Two Cases of Superior Mesenteric Artery Syndrome after Y-Graft Replacement for Juxta-renal Abdominal Aortic Aneurysms

Two Cases of Superior Mesenteric Artery Syndrome after Y-Graft Replacement for Juxta-renal Abdominal Aortic Aneurysms

Syndrom arteria mesenterica superior v souvislosti s Crohnovou chorobou – kazuistika

Superior mesenteric artery syndrome (SMAS) is a rare condition characterized by mechanical compression of the third part of the duodenum between the abdominal aorta and the superior mesenteric artery. The relationship between Crohn‘s disease and SMAS is seldom described in literature, although patients with Crohn‘s disease have many predispositions to its development. We describe the case of a 17-year- -old female patient who has been dia gnosed with Crohn‘s disease for several years and has been experiencing symptoms of abdominal discomfort and significant weight loss for five months. Magnetic resonance imaging was a key method for dia gnosing SMAS. In addition, older contrast computed tomography scans were evaluated retrospectively with regards to the aortomesenteric angle and distance, the reduction of which is a diagnostic criterion for SMAS. Our goal is to highlight the importance of measuring these values in patients with Crohn‘s disease for early detection of the risk of SMAS.

The original modification of Albrecht – Staveley operation in the treatment of Wilkie’s syndrome

Abstract. Presents a clinical case of the treatment of a patient suffering from Wilkies syndrome. Wilkies syndrome (aorto-mesenteric compression of the duodenum) is a compression of the duodenum (its horizontal section) between the abdominal aorta and the superior mesenteric artery. The causes of this disease are asthenic constitutional type, sharp weight loss, etc. A natural complication of Wilkies syndrome is the occurrence of a chronic violation of duodenal patency. The method of choosing treatment for aorto-mesenteric compression is surgery. The most optimal volume of surgery is the formation of duodenojejunoanastomosis according to Albrecht Staveley, however, after this intervention, there is a high risk of a vicious circle syndrome. Patient M., 28 years old, who was scheduled for treatment, noted constant pain in the upper abdomen for 18 years, aggravated after eating, nausea, periodic vomiting, weakness. As a result of the examination, the patient revealed aorto-mesenteric compression of the duodenum. According to multispiral computed tomography of the abdominal organs with contrast at a distance of 40 mm from the mouth of the superior mesenteric artery, a horizontal branch of the duodenum is located between it and the aorta, its diameter at this level is no more than 4 mm, the angle of departure of the superior mesenteric artery from the aorta is 17 degrees. Violation of the passage through the duodenum was confirmed by fluoroscopy of the upper gastrointestinal tract with contrast. The patient underwent surgery. As a method of surgical treatment, an original modification of Albrecht Staveley operation was used, which, in addition to achieving the main goal, is aimed at preventing the development of the vicious circle syndrome. The patient was discharged from the clinic on the 10th postoperative day in satisfactory condition.

Manejo del Síndrome de Arteria Mesentérica Superior

El síndrome de arteria mesentérica superior o también llamado síndrome de Wilkie, consiste en un diagnóstico de exclusión, una condición que causa un cuadro de obstrucción intestinal alta de forma crónica usualmente debido a un acortamiento del ángulo aorto mesentérico y la distancia aortomesentérica. Su clínica se basa en vómitos postprandiales, llenura postprandial, pérdida de peso y suele acompañarse de condiciones adicionales que causan un franco adelgazamiento del paciente. Su valoración y manejo es multidisciplinario e involucra múltiples especialidades médicas y quirúrgicas. El manejo inicial es médico y nutricional y se basa en lograr un claro aumento de peso, sin embargo, muchas veces es fallido y el paciente requiere de cirugía. Cuando esto sucede la técnica ideal con menos morbilidad asociada y mayor resolución de sintomatología consiste en la duodeno yeyunostomía laparoscópica.

Wilkie's syndrome: a serendipitous diagnosis.

Wilkie's syndrome: a serendipitous diagnosis.

The risks, reasons, and costs for 30- and 90-day readmissions after fusion surgery for adolescent idiopathic scoliosis.

With the continued evolution of bundled payment plans, there has been a greater focus within orthopedic surgery on quality metrics up to 90 days of care. Although the Centers for Medicare and Medicaid Services does not currently penalize hospitals based on their pediatric readmission rates, it is important to understand the drivers for unplanned readmission to improve the quality of care and reduce costs. The National Readmission Database provides a nationally representative sample of all discharges from US hospitals and allows follow-up across hospitals up to 1 calendar year. Adolescents (age 10-18 years) who underwent idiopathic scoliosis surgery from 2012 to 2015 were included. Patients were separated into those with and those without readmission within 30 days or between 31 and 90 days. Demographics, operative conditions, hospital factors, and surgical outcomes were compared using the chi-square test and t-test. Independent predictors for readmissions were identified using stepwise multivariate logistic regression. A total of 30,677 patients underwent adolescent idiopathic scoliosis surgery from 2012 to 2015. The rates of 30- and 90-day readmissions were 2.9% and 1.4%, respectively. The mean costs associated with the index admission and 30- and 90-day readmissions were $60,680, $23,567, and $16,916, respectively. Common risk factors for readmissions included length of stay > 5 days, obesity, neurological disorders, and chronic use of antiplatelets or anticoagulants. The index admission complications associated with readmissions were unintended durotomy, syndrome of inappropriate antidiuretic hormone, and superior mesenteric artery syndrome. Hospital factors, discharge disposition, and operative conditions appeared to be less important for readmission risk. The top reasons for 30-day and 90-day readmissions were wound infection (34.7%) and implant complications (17.3%), respectively. Readmissions requiring a reoperation were significantly higher for those that occurred between 31 and 90 days after the index readmission. Readmission rates were low for both 30- and 90-day readmissions for adolescent idiopathic scoliosis surgery patients. Nevertheless, readmissions are costly and appear to be associated with potentially modifiable risk factors, although some risk factors remain potentially unavoidable.

EUS-guided gastroenterostomy for duodenal obstruction secondary to superior mesenteric artery syndrome.

EUS-guided gastroenterostomy for duodenal obstruction secondary to superior mesenteric artery syndrome.

Wilkie’s Weight Loss Wonder: A Case Series

INTRODUCTIONWilkie’s Syndrome, also known as Superior Mesenteric Artery Syndrome (SMAS), is a rare cause of bowel obstruction that can contribute to vague abdominal symptoms on clinical presentation. This syndrome occurs when the aortomesenteric angle decreases, compressing the third portion of the duodenum between the aorta and the superior mesenteric artery. An acute decrease in the mesenteric fat pad cushion between these two blood vessels is the primary etiology, although other causes (e.g., anatomical, postoperative, functional, and pubescent etiologies) have also been described.CASE PRESENTATIONIn the present cases, 2 females with a common history of recent weight loss presented to our institution with similar symptoms of abdominal pain, nausea and vomiting. Each patient was subsequently diagnosed with SMAS following imaging studies. Both patients experienced successful resolution of symptoms with conservative nutritional management.DISCUSSIONCommon presenting complaints of SMAS include nausea, vomiting, early satiety and postprandial pain. These symptoms overlap with other gastrointestinal disorders (i.e., mesenteric ischemia, intestinal volvulus, peptic ulcer disease) making diagnosis difficult. SMAS can be identified through imaging modalities including barium studies and computer tomography. First line therapies typically include conservative nutritional support and promotion of weight gain. If conservative therapies fail, various surgical procedures can be pursued. Delayed diagnosis can lead to further pathological sequelae, including duodenal compromise, ischemia and necrosis. As the syndrome progresses, success of conservative nutritional support is less likely, and surgical correction becomes increasingly necessary.CONCLUSIONTherefore, a clinical goal for SMAS should include as swift a recognition and diagnosis as possible.

Wilkie’s Syndrome Following Weight Loss in a Trauma Patient

Wilkie’s syndrome, or superior mesenteric artery syndrome, is a rare condition of duodenal obstruction caused by compression of the superior mesenteric artery on the third part of the duodenum. The diagnosis should be considered in a patient who has experienced significant weight loss and now presents with persistent vomiting, especially if the vomiting occurs with the patient in the supine position and is alleviated by the lateral or prone position. The diagnosis can be confirmed by imaging studies demonstrating compression of the third part of the duodenum, and the main aim of treatment should be to pass a feeding tube beyond the point of obstruction to allow enteral feeding. The condition improves spontaneously with weight gain. Further treatment options include parenteral feeding and operative bypass in select cases. Here we present a case of Wilkie’s syndrome in a trauma patient with significant weight loss, together with a review of the literature on this interesting topic.

Wilkie's syndrome in an adolescent female patient

<p>One of the rare cases of the upper gastrointestinal tract obstruction is superior mesenteric artery syndrome (SMAS) but potentially life-threatening if not recognized early. It is due to loss of fat pad between the aorta and SMA which will lead to a compression of the third portion of the duodenum. It has a different angle which will lead to different presentations as well as severity. We are reporting the 15 year-old (y/o) female who is medically free, presented to the emergency department (ED) complaining of severe colicky epigastric abdominal pain for the last 5 days in the epigastric area. The diagnosis of SMAS was made after clinical and radiological investigation. After proper supportive resuscitative measures, definitive management of the surgery was done by laparoscopic approach (duodenojejunostomy). The diagnosis of SMA syndrome is considered challenging due to many presentations and might be confused with other clinical conditions. Unless early diagnosed and treated, the outcome might be catastrophic. Medical treatment is attempted first in many cases depending on the severity and presentation but if failed, surgery will be the best option.</p>

Laparoscopic duodenojejunostomy to manage small bowel obstruction due to superior mesenteric artery syndrome after Roux-en-Y gastric bypass.

Superior mesenteric artery (SMA) syndrome (Wilkie or cast syndrome) is a rare disease that was first described in 1842. It is seen in patients most often after dramatic weight loss due to starvation, burns, anorexia nervosa, or bariatric surgery.

S3593 Superior Mesenteric Artery Syndrome: A Rare Cause of Gastrointestinal Obstruction

INTRODUCTION: Superior mesenteric artery syndrome is an uncommon cause of proximal intestinal obstruction that occurs when the abdominal aorta and the superior mesenteric artery compress the distal part of the duodenum. It has been referred to by a variety of other names, including Cast Syndrome, Wilkie’s syndrome and duodenal vascular compression. Here we present the case of a 29-year-old female who was diagnosed with superior mesenteric artery syndrome refractory to conservative treatment. CASE DESCRIPTION/METHODS: The patient is a 29-year-old female with a medical history of generalized anxiety disorder and major depressive disorder who presented to the emergency department (ED) complaining of abdominal pain, nausea, and vomiting for 2 months. Abdominal pain was described as intermittent, sharp, located in the epigastric area, associated with nausea, non-bilious, non-bloody vomiting, bloating, and unintentional weight loss. On physical exam, the patient looked cachectic, with a tender abdomen. Initial workup was remarkable for hypokalemia and hypochloremia. Notable imaging included an abdominal X-ray showing a fluid-filled dilated stomach compatible with gastric outlet obstruction. A computed tomography (CT) scan of the abdomen and pelvis showed marked gastric dilatation with lesser dilatation of the first and second portion of the duodenum with narrowing or compression at the third and fourth portion and proximal jejunum. Additionally there was a decreased aorta mesenteric distance and angle, most likely compatible with a superior mesenteric artery (SMA) syndrome (Figure 1,2,3). The patient subsequently underwent esophagogastroduodenoscopy (EGD) that revealed copious amounts of retained bilious liquid and food material in the proximal stomach with no evidence of gastric outlet obstruction. There were no gross endoluminal lesions in the duodenum, but the sweep could not be traversed due to extrinsic compression likely secondary to SMA syndrome. The patient received adequate intravenous hydration and nasogastric tube (NGT) decompression with improvement of symptoms. After improvement of symptoms the patient left the hospital against medical advice and refused further evaluation. DISCUSSION: Superior mesenteric artery syndrome, although rare, should be considered as one of the differential diagnoses in the presence of partial or complete gastrointestinal obstruction. This can be successfully managed with conservatory measures, thus avoiding surgery which is reserved for refractory cases.Figure 1.: CT scan of the abdomen showing marked gastric dilation (blue arrows).Figure 2.: CT of the abdomen (axial view) showing decreased distance between the abdominal aorta (red arrow) and superior mesenteric artery (blue arrow) consistent with SMA syndrome.Figure 3.: CT of the abdomen (sagittal view) showing decreased distance between the abdominal aorta (red arrow) and superior mesenteric artery (blue arrow) consistent with SMA syndrome.

S2896 A Rare Case of Proximal Intestinal Obstruction from Superior Mesenteric Artery Syndrome

INTRODUCTION: Superior mesenteric artery (SMA) syndrome is a rare disorder that is characterized by compression of the third portion of the duodenum due to narrowing of the angle between the SMA and the aorta. Patients typically present with intermittent postprandial epigastric pain, nausea, and bilious vomiting. We report a case of a 25-year-old female who presents with symptoms of intestinal obstruction, diagnostic evaluation revealing SMA syndrome, and successful duodeno-jejunostomy procedure. CASE DESCRIPTION/METHODS: A 25-year-old female history of cholecystectomy presented with worsening symptoms of nausea, intractable vomiting, postprandial epigastric pain, and twenty pound weight loss for 2 years. She had multiple hospitalizations and extensive gastrointestinal work-up in the past without any identifiable cause of her symptoms. Physical exam, labs, CT abdomen and pelvis, EGD, colonoscopy, and PillCam endoscopy were benign. CT angiography of abdomen and pelvis demonstrated a decreased aorta-superior mesenteric artery angle of 9.1 degrees (normal 38 degrees to 65 degrees) with aorta- superior mesenteric distance of 5.1 mm (normal 10 to 28 mm), and compression of the third part of duodenum, confirming the diagnoses of SMA syndrome. She was initially managed conservatively with duodenal and gastric decompression via NG tube, fluid and electrolyte correction, body positioning, proton pump inhibitors, and nutritional support. Unfortunately, the patient had no improvement in her symptoms and subsequently required duodeno-jejunostomy. Upon completion of the procedure, the patient had complete resolution of her presenting symptoms. DISCUSSION: The diagnosis of SMA syndrome requires a high clinical suspicion in order to obtain abdominal angiography in patients with persistent symptoms despite negative endoscopic and conventional radiographic findings. Diagnosis requires an aorto-mesenteric angle between 6-22 degrees and an aorto-mesenteric distance between 2-8 mm on CT angiography. Patients should initially be managed with conservative therapy. However, if symptoms fail to improve or increase in severity, surgery is the definitive treatment. Surgical options include duodeno-jejunostomy, gastro-jejunostomy, and Strong’s procedure. Duodeno-jejunostomy is the procedure of choice, as it carries a 90% success rate.

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.

S2768 A Rare Case of Small Intestinal Obstruction From Superior Mesenteric Artery Syndrome (SMAS) in Patient With Systemic Sclerosis (SS)

S2768 A Rare Case of Small Intestinal Obstruction From Superior Mesenteric Artery Syndrome (SMAS) in Patient With Systemic Sclerosis (SS)

S2819 Evaluating All Angles: Wilkie's Syndrome—A Rare Cause of Intestinal Obstruction

INTRODUCTION: Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction. The prevalence of SMA syndrome is estimated at less than 0.3%. Normally, the angle between the SMA and aorta is 38-65 degrees maintained by mesenteric fat padding. The mechanism of intestinal obstruction is due to exaggerated acute angularity of the SMA caused by excessive fat loss, leading to compression of the third part of the duodenum as it travels between the SMA and aorta. There are multiple predisposing factors that can increase the angularity, such as anorexia nervosa, kyphoscoliosis, and bariatric surgery. However, there are limited reports of SMA syndrome secondary weight loss exacerbated by chemotherapy. CASE DESCRIPTION/METHODS: We present a 22-year old female with a history of aplastic anemia, post allogenic bone-marrow transplant with cyclophosphamide/fludarabine/anti-thymocyte globulin conditioning therapy, who presented with nausea and vomiting for 4 days and a 9 kg loss in weight since conditioning therapy. Physical examination revealed a severely dehydrated patient with peri-umbilical tenderness. The patient had presented with similar symptoms 1 month prior, with a normal EGD, and resolution of symptoms with supportive care. On readmission CT-Abdomen revealed a massively distended stomach, first, and second portions of the duodenum, and complete collapse of the duodenum at the level of the SMA. CT-Angiography revealed acute angulation of the SMA-aortic takeoff at 20 degrees, establishing the diagnosis of SMA syndrome. The patient underwent nasogastric decompression and laparoscopic duodenojejunostomy resulting in a successful bypass. DISCUSSION: Physicians should be wary of this rare etiology of duodenal obstruction and its clinical presentation. A high index of suspicion should be employed for young patients presenting with signs and symptoms of intestinal obstruction with a history of weight loss. Delayed diagnosis can lead to significant morbidity, due to electrolyte abnormalities or perforation. CT-Angiography is the imaging modality of choice to establish the diagnosis. However, the diagnosis may be overlooked, as radiological findings do not always correlate with clinical findings. Additionally, some patients may experience intermittent symptomatic compression of the duodenum, leading to a delay in diagnosis, as illustrated with our patient. Depending on initial management, it is recommended that once symptom free and patency of the duodenum is achieved, patients begin a dietary regimen.Figure 1.: 3D Reconstructed CT-Angiography revealing severely distended stomach, first, and second portion of the duodenum.Figure 2.: CT Angiography revealing severe acute angularity of the SMA-aortic takeoff. Black arrow—Celiac artery, Maroon arrow—Aorta, Blue arrow—Superior Mesenteric Artery.

Vomiting in Pediatric Patients.

This classic team-based learning activity is specifically designed for emergency medicine bound medical students and junior residents; however, general pediatrics residents and general medical students may also benefit from this activity. Senior residents and fellows felt that the cases were too basic for them but enjoyed acting as facilitators. Vomiting is a common chief complaint in pediatric patients seen in the Emergency Department. 1-3 Presentations include acute, chronic, and cyclic vomiting, with underlying etiologies such as toxin injection, emotional disturbances, and movement disequilibrium. 1 By understanding these various pathways, it is helpful for physicians to distinguish between gastrointestinal and non-gastrointestinal causes of vomiting. 1 Most cases of vomiting in the pediatric population are self-limiting and require only supportive treatment; however, physicians must be able to recognize red flags associated with vomiting that warrant further evaluation. 1,3 This task may be challenging for medical students and residents in emergency medicine and those with infrequent exposure to pediatric patients. Therefore, this team-based learning activity was developed to help junior learners in differentiating non-emergent and emergent cases of pediatric vomiting. This activity aids learners in formulating a differential based on age, history, and characteristics of vomiting. We also review specific causes of pediatric vomiting that physicians cannot miss including intussusception, pyloric stenosis, malrotation, intestinal atresia, and intracranial pathology. By the end of this TBL session, learners should be able to:Identify red flag symptoms that should prompt referral for urgent intervention by GI or surgical specialists.Recognize how chronicity of the vomiting can alter the differential diagnosisDescribe the varying pathways that can cause nausea and vomiting.Determine the necessity of imaging tests to confirm and possibly treat various causes of vomiting.Interpret imaging studies associated with specific causes of vomiting. Classic Team Based Learning (cTBL). Learners and instructors provided verbal feedback after the session in a large group format. Learners were specifically asked if they felt the session was education, relevant, high-yield and level appropriate. One instructor provided written feedback to the cases as well. Overall learners and instructors found the session to be engaging, informative and educational. Learners felt that the session was level appropriate for medical students and junior residents. As a result of feedback from the session, several of the iRAT/gRAT questions were adjusted and the group application cases were re-written and implemented. Overall, the educational content and delivery was effective. This session was presented to a group of emergency medicine students, interns and residents. Learners were divided into smaller groups, and each group had a variety of level of learners, including pediatric emergency medicine fellows, present. The fellows, while not necessary to the delivery of the TBL, were extremely helpful in aiding the residents during the session. The final debriefing and answer review were essential to ensure that learners met all educational objectives and fully understood the materials. Pediatric vomiting, intussusception, pyloric stenosis, intestinal atresia, malrotation, gastroesophageal reflux disease, superior mesenteric artery (SMA) syndrome, hyperemesis.

Superior mesenteric artery syndrome complicating the clinical presentation and treatment of inflammatory bowel disease in a pediatric patient

article: Superior mesenteric artery syndrome complicating the clinical presentation and treatment of inflammatory bowel disease in a pediatric patient - Minerva Pediatrica 2020 Oct 27 - Minerva Medica - Journals

S2813 Mimicking Superior Mesenteric Artery Syndrome: A Case of Duodenal Malrotation

INTRODUCTION: Intestinal malrotation is a rare cause of mechanical bowel obstruction in adults. We describe a case of duodenal malrotation mimicking superior mesenteric artery syndrome. CASE DESCRIPTION/METHODS: A 22-year-old male with history of schizophrenia presented with abdominal pain and distension. He fasted for the past two months with 40 lbs weight loss, limiting himself to water in order “challenge himself.” The day prior to arrival, he ended his fast with a “large meal.” He immediately had abdominal pain and distension. Vital signs were normal. Labs were only remarkable for hypokalemia 3.4 mmol/g and trace levels of urinary ketones. CT revealed gastric distension filled with large air-fluid levels. An NG tube was placed for decompression with significant improvement. EGD revealed LA grade A esophagitis, mild diffuse gastric erythema, and a single 8 mm gastric ulcer with clean base. The endoscopist reported difficulty traversing from the second to third portion of duodenum and was concerned about extrinsic compression. MRE and upper GI series showed no obstruction. Both studies revealed that the duodenum did not cross midline and loops of jejunum in the right upper quadrant, indicative of malrotation. The patient improved gradually over several days and resumed a full diet. He was discharged to inpatient psychiatry with follow-up to assess for further surgical intervention. DISCUSSION: Bowel obstruction results from a mechanical or functional impedance of the intestines. Duodenal malrotation is a rare cause of mechanical obstruction. In adults, it occurs between 2%–5% of patients and most remain asymptomatic throughout life. Symptomatic patients typically present postprandially such as in ours, with also emesis, pain, failure to thrive, weight loss, and malabsorption. In our patient, the weight loss may likely have been due to poor intake due to the malrotation rather than the patient wishing to “challenge himself.” In a rare subset of malrotation patients, they present with a potentially life-threatening condition called acute midgut volvulus. Abdominal CT is the first line of screening and oral contrast studies are needed to confirm diagnosis. Treatment includes enteric tube for decompression, bowel rest, and possible surgical intervention. Patients presenting as adults with intestinal malrotation may be misdiagnosed, which can delay management. However, duodenal malrotation should be in the differential for patients presenting with obstruction without significant surgical history.Image 1.: The duodenum does not cross midline to the left with loops of jejunum seen in the right upper quadrant, indicative of malrotation.Image 2.: EGD image revealing narrowed second and third portion of the duodenum concerning for external compression.Image 3.: Descending duodenum is normal, however the 2nd portion of the duodenum does not cross the midline, but rather extends to the right. There is no distention of the duodenum to suggest SMA syndrome.