Superior Mesentric Artery Syndrome in a Patient with Subacute Intestinal Obstruction: A Case Report

Abstract

Superior Mesenteric Artery (SMA) syndrome is one of the rare cause of proximal small bowel obstruction wherein, the third part of the duodenum is compressed between the SMA at its origin and abdominal aorta due to decreased angulations in these two vessels. This decreased angulation exerts a compression effect on third part of the duodenum, resulting in duodenal obstruction which may be complete or partial. There are number of causes which can lead to this entity and will be discussed briefly. Here we report imaging findings of such a rare cause of proximal small bowel obstruction in a young male patient who presented to the emergency surgical department with non specific symptoms of pain abdomen and abdominal fullness. Patient was evaluated under the standard protocol in management of abdominal pain. General physical examination, erect and supine radiograph were taken. On barium meal follow-through examination, there was paucity of contrast agent distal to the second part of duodenum with proximal dilation of stomach, first and second part of duodenum which raised us the possibility of SMA syndrome. Reconstructed CECT abdomen confirmed the decreased angulation between SMA and abdominal aorta and diagnosed it as SMA syndrome. Findings were correlated on duodenojejunostomy anastomotic surgical procedure. Diagnosing and reporting such a case of SMA syndrome is of utmost importance because the clinical presentation being non-specific pertaining to small bowel obstruction which may pose a diagnostic difficulty to the surgeon and with the further delay in diagnosis, patients may end up with chronic symptoms and complications of the disease, repeated hospital visits and electrolyte abnormalities.

Keywords: Barium studies; Decreased aortomesenteric angle; Wilkie’s syndrome.

[Table/Fig-1]:

Barium study showing dilated proximal part (white star*) and narrowed third part (white circle 0) of duodenum with no passage of contrast seen distally. Black arrow;stomach.

[Table/Fig-2]:

On repositioning the patient to prone, the contrast is seen passing into the third and fourth part (arrowheads) of duodenum. Black arrow; stomach.

[Table/Fig-3]:

CECT showing dilated stomach (white star) and duodenum up to the level of superior mesenteric artery (black arrow).

[Table/Fig-4]:

Reconstructed CECT image shows reduced angle distance between SMA and abdominal aorta. ANGLE was reduced to 18 degrees and distance was approx 7mm (curved arrow)diagnostic of SMA syndrome. Note the thin built of patient in this sagittal reconstructed CT image with significantly less retroperitoneal fat.