P1840 - Successful Treatment of Superior Mesenteric Artery Syndrome in a Cirrhotic Patient with Percutaneous Endoscopic Gastrojejunostomy

Sneha Shaha, DO¹, Yinglin Gao, DO¹, James Huang, MD², Eric Imbertson, MD², Sherman Rhee, MD², Cindy Cai, MD^2
1Loma Linda University Medical Center, Loma Linda, CA; ²VA Loma Linda Healthcare System, Loma Linda, CA

Introduction: Superior mesenteric artery syndrome (SMAS) is a rare cause for proximal small bowel obstruction (PSBO) usually associated with weight loss. It features compression of the 3^rd portion of the duodenum by SMA due to narrow aortomesenteric angle from loss of mesenteric fat pad. Patients with decompensated cirrhosis are highly susceptible to malnutrition. We report a case of SMAS in a cirrhotic patient treated with percutaneous endoscopic gastrojejunostomy (PEG-J).

Case Description/Methods: A 61year old Caucasian male with a history of alcoholic cirrhosis presented with a week of diffuse abdominal pain associated with nausea, vomiting, anorexia, and constipation after a 25 pound weight loss. His cirrhosis was complicated with esophageal varices, hepatic encephalopathy and refractory ascites treated successfully with a trans-jugular intrahepatic portosystemic shunt. His Model for End-Stage Liver Disease Sodium (MELD-Na) score on admission was 21 with a Child-Pugh (CP) class of C and serum albumin of 2.8. Contrast-enhanced computed tomography showed compression of the third portion of the duodenum with an aortomesenteric angle at 20⁰. High-grade obstruction from the 2^nd and 3^rd portion of the duodenum without intraluminal lesions was confirmed during esophagogastroduodenoscopy (EGD). Besides conservative medical management, a 24 Fr PEG tube with a 12 Fr extension tube into the proximal jejunum was placed endoscopically through the guidewire under fluoroscopy. He recovered well with the gastric venting via G-port and enteral nutrition via J-port. Two months later, another EGD showed complete resolution of the obstruction, and G-J tube was pulled out. Patient has maintained adequate oral feeding with steady weight gain, and recent MELD-Na and CP class all back to his baseline of 12 and B, respectively.

Discussion: To our knowledge, this is the first reported SMAS in a cirrhotic patient. This case shed some light on early recognition of SMAS as a cause for PSBO in a cirrhotic patient with severe weight loss. If not treated promptly, this could result in significant morbidity and mortality. Medical management remains the primary treatment for SMAS with a goal of gastric decompression, fluid resuscitation, correction of electrolytes and reversal of weight loss by enteral or parenteral nutrition. PEG-J provides a safe and effective treatment for SMAS with both gastric decompression and post-duodenal nutritional support.


Disclosures:


Sneha Shaha, DO¹, Yinglin Gao, DO¹, James Huang, MD², Eric Imbertson, MD², Sherman Rhee, MD², Cindy Cai, MD². P1840 - Successful Treatment of Superior Mesenteric Artery Syndrome in a Cirrhotic Patient with Percutaneous Endoscopic Gastrojejunostomy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.