Resolution of refractory superior mesenteric artery syndrome with laparoscopic duodenojejunostomy: pediatric case series with spectrum of clinical imaging

Abstract

Background: Superior mesenteric artery (SMA) syndrome is an uncommon condition resulting in partial small bowel obstruction because of external compression of the third portion of the duodenum between the SMA anteriorly and the aorta posteriorly. SMA syndrome often presents with postprandial nausea, bilious vomiting, and abdominal pain with associated weight loss. Onset of symptoms can be acute (occurring in the setting of rapid weight loss because of trauma/surgery) or can be vague and chronic over many years.

Case reports: We present two cases of female adolescents who presented with symptoms of duodenal obstruction attributed to SMA syndrome. Both failed conservative treatment with weight gain and underwent successful laparoscopic duodenojejunostomy procedures with resolution of duodenal obstruction.

Conclusion: In the differential diagnosis of persistent nausea and bilious vomiting, even in the setting of an eating disorder, SMA syndrome should be considered. Upper gastrointestinal examination is the primary modality for diagnosing SMA syndrome, but ultrasound is an inexpensive, rapid screening tool for patients with unexplained abdominal pain. Abdominal computed tomography may also be helpful in selected patients. Conservative therapy consisting of nutritional support to enhance weight gain is usually sufficient and is accomplished with placement of a nasojejunal feeding tube past the point of duodenal compression. When conservative therapy fails, laparoscopic duodenojejunostomy can provide definitive relief of the obstruction.

Keywords: Duodenal obstruction; superior mesenteric artery syndrome.

Figure 1.

Upper gastrointestinal examination with barium obtained on initial presentation in case 1 revealed a massive enlargement of the stomach and proximal duodenum with abrupt cutoff point as the duodenum crosses the midline (arrow). Contrast did not pass through the horizontal portion of the duodenum while the patient was supine; however, contrast easily passed through with the patient in the left lateral decubitus or prone positions.

Figure 2.

Coronal computed tomography image demonstrates the massively distended esophagus, stomach, and proximal duodenum in case 1. There is an abrupt cutoff point of the duodenum just prior to it crossing the midline (white arrow) at the level of the superior mesenteric artery (black arrow). The distal bowel is collapsed and compressed.

Figure 3.

Sagittal computed tomography image shows the narrowed aortomesenteric angle (arrow) in case 1.

Figure 4.

Endoscopic view shows deformation and narrowing of the third portion of the duodenum in case 2. No etiology of obstruction intrinsic to the bowel was identified on this examination.

Figure 5.

Upper gastrointestinal examination with barium demonstrates distention of the stomach and proximal duodenum and a sharp vertical line across the third portion of the duodenum (arrow) consistent with extrinsic compression in case 2. During this examination, there was antiperistaltic reflux of contrast into the stomach.