NYU Langone Medical Center/ Woodhull Medical Center New York, New York
Introduction: Superior mesenteric artery (SMA) syndrome is a rare and potentially life-threatening disorder that is caused by the compression of the third part of the duodenum between the SMA and the origin. We present a rare case of intermittent SMA syndrome in a young patient who presented with symptoms of gastric outlet obstruction and was diagnosed with SMA syndrome based on the radiology on admission. During the hospital course, the symptoms improved and repeat imaging showed the resolution of the compression of the duodenum.
Case Description/Methods: A 19-year-old male patient with no past medical history presented with epigastric abdominal pain associated with non-bilious, non-bloody vomiting for two days. He endorsed 30 kilograms of intentional weight loss in the last six months, using a low-fat diet. On physical examination, the patient was severely malnourished with a body mass index (BMI) of 18. Abdominal examination showed moderate distention with mild tenderness in the epigastric area. CT scan of the abdomen revealed gastro-duodenal distension with a transition point at the third part of the duodenum due to compression between the SMA and aorta with an acute aortomesenteric angle close to 8 degrees. Gastric decompression was done using a nasogastric tube, draining 1500 mL of bilious fluid. IV hydration and electrolyte supplementation were given. Gastroduodenoscopy on day two of admission ruled out obstruction. By the third day of hospitalization, the patient's abdominal pain and vomiting resolved. CT angiography of the abdomen confirmed normalization of the aortomesenteric angle. Oral feeding was started and he was discharged on day six of hospitalization.
Discussion: SMA syndrome may have an acute, chronic, or intermittent presentation. The SMA is surrounded by a mesenteric fat pad which lies between the SMA and the aorta. In our case, the loss of the aortomesenteric fat pad secondary to acute weight loss placed the patient at risk for intermittent positional compression of his duodenum. This case highlights the importance of considering SMA syndrome in the context of aggressive dieting and eating disorders.
