Superior Mesenteric Artery (SMA) Syndrome Case of the Month - October 2017 Jane Meng, PGY-2
Case Study 19F presented to the ER with: Right upper quadrant pain Nausea VomiKng Same day US study was negakve for cholecyskks and cholelithiasis Past medical history of gastric distension NYD requiring NG tube decompression
Imaging Findings CECT Superior Mesenteric Artery (SMA) Syndrome Compression of the 3 rd porkon of the duodenum between the superior mesenteric artery (SMA) and abdominal aorta
Imaging Findings CECT Distended proximal duodenum Dilated stomach AMD 5 mm with compression of the transverse duodenum Decreased aortomesenteric distance (AMD) between abdominal aorta and SMA (N = 10-34 mm) on axial plane
Imaging Findings Abdominal US AMD 5 mm with compression of the transverse duodenum Decreased aortomesenteric distance (AMD) between abdominal aorta and SMA (N = 10-34 mm) on transverse plane
Imaging Findings CECT Decreased aortomesenteric angle (AMA) on the sagizal plane (N = 28-65 ) AMA 12 Transverse duodenum
Imaging Findings Upper GI Series Barium Upper GI Series Extrinsic compression on transverse duodenum Proximal duodenal dilatakon May see ankperistalkc flow of barium proximal to compressed transverse duodenum
SMA Syndrome Clinical PresentaKon Signs & Symptoms Postprandial pain Epigastric pain Weight loss VomiKng Nausea
SMA Syndrome Predisposing Factors 1. Weight loss DepleKon of retroperitoneal fat around transverse duodenum Chronic waskng diseases, catabolic states Anorexia, malabsorpkon 2. PostoperaKve states Scoliosis surgery Bariatric surgery 3. Anatomical/congenital anomalies Cephalad dislocakon of duodenum related to high inserkon of ligament of Treitz Low origin of SMA
SMA Syndrome - DifferenKal Diagnosis A. Duodenal bowel obstruckon Gastroduodenoscopy can assess for intraluminal obstruckve causes B. Duodenal stricture Ohen posknflammatory secondary to duodenal ulcer C. IntesKnal scleroderma Correlate with non-intesknal findings of scleroderma
SMA Syndrome - Treatment 1. Non-operaKve PosiKonal maneuvers to relieve pain: Prone Knee-chest Leh lateral decubitus NG tube decompression of stomach Increase body weight with parenteral or tube feeds 2. OperaKve Duodenojejunostomy Gastrojejunostomy
SMA Syndrome - Other ConsideraKons Nutcracker syndrome can occur simultaneously Also due to decreased AMA and AMD Compression of leh renal vein between SMA and abdominal aorta
SMA Syndrome - Other ConsideraKons Nutcracker syndrome clinical presentakon Hematuria Leh flank pain Pelvic congeskon Varicocele in males Leh-sided pelvic varicosikes
Case Study 19F presented to the ER with: Right upper quadrant pain Nausea VomiKng Same day US study was negakve for cholecyskks and cholelithiasis Past medical history of gastric distension NYD requiring NG tube decompression Treated non-operakvely, symptoms improved
References 1. Lamba R, Tanner DT, Sekhon S, McGahan JP, Corwin MT, Lall CG. MulKdetector CT of vascular compression syndromes in the abdomen and pelvis. Radiographics. 2014;34:93 115. 2. Unal B, Aktas A, Kemal G, Bilgili Y, Guliter S, Daphan C, Aydinuraz K: Superior mesenteric artery syndrome: CT and ultrasonography findings. Diagn Interv Radiol 2005;11:90 95.