Superior Mesenteric Artery Syndrome in Anorexia Nervosa: A Case Report and a Systematic Revision of the Literature.

BACKGROUND: Superior mesenteric artery syndrome (SMAS) is a rare condition caused by the compression of the duodenum, which may occur in the case of fast weight loss. Currently, the relationship between superior mesenteric artery syndrome and anorexia nervosa is still unclear. The aim of this study is to identify the precocious clinical signs and symptoms of SMAS in patients affected by anorexia nervosa so as not to delay the diagnosis. METHODS: We present the clinical case of a young female patient with anorexia nervosa complicated by SMAS. We performed a literature review of SMAS in children affected by anorexia nervosa between 1962 and 2023, according to the PRISMA Extension Guide for Scoping Reviews. RESULTS: Reviewing the literature, 11 clinical cases were described for the pediatric age. The median age at diagnosis was 17 years (ranging from 13 to 18 years). The diagnosis of SMAS may be challenging as symptoms overlap those of anorexia, but it should be kept in mind mostly in cases of post-prandial abdominal pain, anxiety or depression, nausea, vomiting, and weight loss. CONCLUSION: Even specific clinical symptoms may act as flag tags to drive attention to this rare but potentially fatal condition.

Dynamic ultrasonography for optimizing treatment position in superior mesenteric artery syndrome: Two case reports and review of literature.

BACKGROUND: Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction by extrinsic compression between the SMA and the aorta (SMA-Ao). Although the left lateral recumbent position is considered effective in the treatment of SMA syndrome, individual variations in the optimal patient position have been noted. In this report, we present two elderly cases of SMA syndrome that exhibited rapid recovery due to ultrasonographic dynamic evaluation of the optimal position for each patient. CASE SUMMARY: Case 1: A 90-year-old man with nausea and vomiting. Following diagnosis of SMA syndrome by computed tomography (CT), ultrasonography (US) revealed the SMA-Ao distance in the supine position (4 mm), which slightly improved in the lateral position (5.7-7.0 mm) without the passage of duodenal contents. However, in the sitting position, the SMA-Ao distance was increased to 15 mm accompanied by improved content passage. Additionally, US indicated enhanced passage upon abdominal massage on the right side. By day 2, the patient could eat comfortably with the optimal position and massage. Case 2: An 87-year-old woman with vomiting. After the diagnosis of SMA syndrome and aspiration pneumonia by CT, dynamic US confirmed the optimal position (SMA-Ao distance was improved to 7 mm in forward-bent position, whereas it remained at 5 mm in the supine position). By day 7 when her pneumonia recovered, she could eat with the optimal position. CONCLUSION: The optimal position for SMA syndrome varies among individuals. Dynamic US appears to be a valuable tool in improving patient outcomes.

Acute superior mesenteric artery syndrome complicated by severe gastric, pancreatic and renal ischaemia.

Superior mesenteric artery syndrome (SMAS) is a rare and potentially life-threatening cause of small bowel obstruction in which the superior mesenteric artery impinges on the third portion of the duodenum. SMAS is typically encountered in patients with low body fat and a history of rapid weight loss and is often diagnosed as a chronic or subacute condition. Here, we describe a case of a healthy adolescent boy without typical SMAS prodromal symptoms presenting with a severe, hyperacute proximal small bowel obstruction due to SMAS. Complications arising from massive gastric and duodenal distension, including gastric, pancreatic and renal ischaemia, necessitated emergent surgical intervention consisting of the duodenojejunostomy bypass with partial gastric resection. The patient recovered without significant lasting consequences.

Laparoscopic lateral duodenojejunostomy for pediatric superior mesenteric artery compression syndrome: a cohort retrospective study.

PURPOSE: There are only a few case reports of laparoscopic lateral duodenojejunostomy (LLDJ) in children with Wilkie's syndrome, also known as superior mesenteric artery compression syndrome (SMAS). We aimed to describe our laparoscopic technique and evaluate its outcomes for SMAS in children. METHODS: From January 2013 to May 2021, SMAS children who received LLDJ were included. The procedure was carried out utilizing the four-trocar technique. The elevation of the transverse colon allows good exposure of the dilated and bulging second and third sections of the duodenum. Using a linear stapler, we established a lateral anastomosis connecting the proximal jejunum with the third part of the duodenum. Following that, a running suture was used to intracorporeally close the common enterotomy. Clinical data on patients was collected for analysis. The demographics, diagnostic findings, and postoperative outcomes were analyzed retrospectively. RESULTS: We retrospectively analyzed 9 SMAS patients (6 females and 3 males) who underwent LLDJ, aged between 7 and 17 years old. The mean operative time was 118.4 ± 16.5 min and the mean estimated blood loss was 5.6 ± 1.4 ml. There were no conversion, intraoperative complications or immediate postoperative complications. The mean postoperative hospital stay was 6.8 ± 1.9 days and the mean follow-up time was 5.4 ± 3.0 years. During follow-up, seven patients (77.8%) experienced complete recovery of symptoms prior to surgery. One patient (11.1%) still had mild vomiting, which resolved with medication. Another patient (11.1%) developed psychological-induced nausea, which significantly improved after treatment with education, training and diet management. CONCLUSIONS: LLDJ represents a feasible and safe treatment option for SMAS in well-selected children. Further evaluation with more cases and case-control studies is required for the real benefits.

Superior mesenteric artery syndrome and anorexia nervosa: a case report.

BACKGROUND: Superior mesenteric artery (SMA) syndrome is an underdiagnosed complication in anorexia nervosa (AN) patients, which results from weight loss-induced atrophy of the mesenteric fat pad, causing compression of the third part of the duodenum. SMA syndrome can be life-threatening as its nonspecific symptomatology often results in a delayed diagnosis. It is a rare condition, but its true prevalence may be higher than the reported numbers. A history of persistent nausea and vomiting after oral intake and weight loss in AN should raise suspicion about this diagnosis, as weight loss is the most significant factor in this diagnosis. Other high-risk factors include rapid, extreme weight loss, anatomical abnormalities, or a history of prior abdominal or spinal surgeries. CASE PRESENTATION: The patient presented in this report was a 26-year-old Caucasian female with a history of severe enduring anorexia nervosa. This patient suffered from an insidious case of SMA syndrome secondary to AN. This patient presented with vague symptoms of nausea and vomiting, persistent abdominal pain, and rapid weight loss. The patient was successfully treated but could have had a much different outcome if the diagnosis had been further delayed. CONCLUSIONS: An awareness of SMA syndrome and its clinical presentation within similar populations can prevent complications and even fatalities that come with it.

Incidence and Potential Risk Factors of Superior Mesenteric Artery Syndrome After Spinal Corrective Surgery in Patients with Adult Spinal Deformity.

OBJECTIVE: This study aimed to determine the incidence and potential risk factors of superior mesenteric artery syndrome (SMAS) after corrective spinal surgery in patients with adult spinal deformity (ASD). METHODS: In total, 102 patients (67.6 ± 8.4 years; 8 male/94 female; body mass index (BMI); 22.4 ± 3.6 kg/m2) with ASD treated by spinal correction surgery were enrolled. Preoperative and postoperative spinal parameters, including thoracolumbar kyphosis (TLK: T10-L2) and upper lumbar lordosis (ULL: L1-L4) were measured. To evaluate the potential risk factors of SMAS, the angle and the distance between the superior mesenteric artery and aorta, the aortomesenteric angle (AMA) and aortomesenteric distance (AMD), were evaluated pre- and postoperatively. Based on the postoperative AMA, AMD, and abdominal symptoms, the patients were diagnosed with SMAS. Correlations between demographic data or spinal parameters and AMA and AMD were assessed. RESULTS: Two (2.0%) patients were diagnosed with SMAS. Postoperative TLK significantly correlated with postoperative AMA (P = 0.013, 0.046). Postoperative ULL was significantly correlated with postoperative AMD (ß = -0.27; P = 0.014). CONCLUSION: The incidence of SMAS after corrective spinal surgery in patients with ASD was 2.0%. Postoperative smaller TLK and greater ULL can be risk factors for developing SMAS. Spine surgeons should avoid overcorrection of the upper lumbar spine in the sagittal plane to prevent SMAS.

Understanding the diagnosis of superior mesenteric artery syndrome: analysis of the location of duodenal impression on upper gastrointestinal studies.

BACKGROUND: Upper gastrointestinal (GI) contrast studies are frequently requested to aid superior mesenteric artery syndrome diagnosis, a rare entity. Compression of the third duodenal part is expected to be mid-to-left of the midline where the superior mesenteric artery arises from the aorta; however, a duodenal impression to the right of the midline due to normal anatomic impression by the inferior vena cava (IVC) is often encountered and frequently misdiagnosed. OBJECTIVE: The purpose of this study was to determine the frequencies of (1) normal right-of-midline duodenal impressions and (2) mid-to-left of midline compressions in upper GI studies in a tertiary pediatric referral center. MATERIALS AND METHODS: All upper GI studies performed at our institution over 2 years were retrospectively evaluated to determine whether the duodenum had vertical duodenal impression to the right of the vertebral midline, mid-to-left of the vertebral midline, or no identifiable duodenal impression at all. RESULTS: In total, 538 upper GI studies were included in this analysis. A total of 275 male and 247 female patients between 0 and 17 years of age (median: 6 years, range: 1 month-17 years) were included. Of 538 total upper GI studies, there were 240 studies (44.6%) with a right-of-midline impression. There were only 10 studies (1.9%) with a mid-to-left of midline compression, and 9/10 also showed a concurrent right-sided impression sign. CONCLUSION: Right-of-midline duodenal impression is a normal anatomic finding caused by the IVC and should not be confused with superior mesenteric artery syndrome. In the presence of an appropriate clinical context, proximal duodenal dilation, "to-and-fro" motion of contrast, and duodenal impression at mid-to-left of midline, a diagnosis of superior mesenteric artery syndrome should be considered.

Massive Gastric Dilatation and Multi-Organ Ischemia Due to Superior Mesenteric Artery Syndrome: A Rare Case Report.

BACKGROUND Superior mesenteric artery (SMA) syndrome, a rare condition in which the SMA and aorta occlude the third duodenal portion, can cause serious complications. We present the case of an 83-year-old Japanese man who presented with shock because of massive gastric dilatation due to SMA syndrome and developed multi-organ ischemia. CASE REPORT The day before admission, the patient had visited the emergency department with abdominal pain and was sent home following spontaneous symptom resolution, but experienced abdominal pain flare-up. His history included diabetes mellitus, hypertension, gastric ulcer, prostatic hypertrophy, esophageal hiatal hernia, and esophageal cancer. Plain computed tomography showed gastric dilatation and obstruction of the duodenal third portion by the SMA, leading to SMA syndrome diagnosis. Since a nasogastric tube could not be manually inserted into the stomach and the gastric dilatation could not be decompressed, the tube was inserted endoscopically. Endoscopy revealed mechanical obstruction of the gastric cardia and gastric mucosal ischemia. He was admitted to intensive care, and blood pressure was maintained with vasopressors and blood transfusion. The next day, contrast-enhanced computed tomography performed for persistently elevated lactate levels revealed extensive ischemia affecting multiple gastrointestinal organs. Surgery and other treatments were considered too risky due to the patient's advanced age and condition. Best supportive care was administered after discussion with the family, and he died on the second day of hospitalization. CONCLUSIONS SMA syndrome with extensive ischemia and infarction is rare. Given this, clinicians should remain vigilant for its potential complications.

Aorto-mesenteric compass syndrome (Wilkie's syndrome) in the differential diagnosis of chronic abdominal pain.

A woman in her 40s was admitted to hospital with weight loss, asthenia, persistent abdominal pain and post-prandial nausea and vomiting. Other comorbidities were anxiety-depressive disorder, gastro-oesophageal reflux disease and fibrocystic mastopathy. On admission her body mass index (BMI) was 15.57 kg/m2 with a reported weight loss of 6 kg during the last 3 months. The patient underwent a double contrast abdominal CT scan, which showed that the third portion of the duodenum appeared to be compressed between the superior mesenteric artery and the abdominal aorta. After a multidisciplinary evaluation, a conservative approach and nutritional supplementation was decided upon and administered. At the 1-year follow-up the symptoms had greatly improved; the epigastric pain, although persistent, was reduced, also due to the weight gain to 50 kg (BMI 19.5 kg/m2). Wilkie's syndrome, in its acquired form, predominantly affects young women after rapid weight loss. In the diagnostic work-up, case history, physical examination and radiological findings play a key role.

Superior mesenteric artery syndrome in an 8-year-old boy: a case report.

BACKGROUND: Superior mesenteric artery syndrome (SMAS), also known as Wilkie's syndrome, is a rare disease that mainly presents as intestinal obstruction with a variable incidence ranging from 0.013 to 0.3% (Salehzadeh et al. in Case Rep Gastrointest Med, 2019, 10.1155/2019/3458601). In this syndrome, the third part of the duodenum, located between the abdominal aorta and the superior mesenteric artery, is wholly or partially obstructed (Mosalli et al. in J Pediatr Surg 46:e29-31, 2011). Case presentation An 8-years-old Arabian male patient was admitted to the gastrointestinal department at the pediatric hospital in Damascus, Syria, with complaints of chronic abdominal pain and periodic vomiting since he was two years old. At the age of Seven, he was diagnosed with appendicitis, and after two months of persistent symptoms, he was diagnosed with an umbilical hernia. Finally, after a long time of suffering, he was diagnosed with SMAS and underwent a successful surgical operation. After 3 months of follow-up, he was in good health with no symptoms. CONCLUSION: Whenever a patient complains of vomiting and chronic abdominal pain, intestinal obstruction is suspected, Common differential diagnoses were excluded and the cause is anonymous, we should consider superior mesenteric artery syndrome.

A Case of Biliary Cast Syndrome with Cholangiocarcinoma-like Lesion in a Patient with No History of Liver Transplantation.

Background and Objectives: Biliary cast syndrome, which was first reported in 1975, is a rare disease that occurs after liver transplantation. The incidence is even lower in patients who have not undergone liver transplantation. This study reports a rare case of biliary cast syndrome with cholangiocarcinoma-like lesions in a patient who did not undergo liver transplantation. Case Report: Herein, we report a case of a 69-year-old man with right upper quadrant pain and elevated levels of alkaline phosphatase and gamma-glutamyl transferase, who had a history of total gastrectomy for gastric cancer and laparoscopic cholecystectomy for acute cholecystitis. Computed tomography (CT) revealed longitudinal bile stones in the extrahepatic and intrahepatic bile ducts and abrupt narrowing of the left main bile duct accompanied by a narrowing of the upstream bile duct in the left lobe of the liver. Based on the CT findings, the removal of the bile stones in the bile duct and additional examinations of the suspected cholangiocarcinoma were performed. The patient's symptoms improved, and examinations for suspected cholangiocarcinoma showed no abnormal findings, and he was discharged one month later. Conclusions: The purpose of this case report is to share a rare case of Biliary Cast Syndrome (BCS) occurring without liver transplantation. Additionally, the report aims to share image findings that mimic cancer in BCS, with the goal of reducing unnecessary repetitive biopsies, minimizing patient discomfort, and decreasing unnecessary costs by aiding in the diagnosis of BCS.

Food Insecurity Leading to Superior Mesenteric Artery Syndrome Managed Successfully with Endoscopic Gastrojejunostomy Stent.

BACKGROUND Food insecurity describes the lack of adequate and reliable access to food due to insufficient resources. The condition affects over one-quarter of the world's population and is exacerbated by factors such as conflicts, climate variability, rising costs of nutritious food, and economic slumps; these challenges are amplified by poverty and inequality. Food insecurity is associated with many negative health outcomes, such as iron deficiency anemia, poor oral health, and stunting of growth in children. CASE REPORT We present the case of a patient who had significant weight loss related to food insecurity then developed a rare adverse health outcome: superior mesenteric artery (SMA) syndrome. SMA syndrome is a condition in which reduction in the angle formed by the proximal SMA and aorta, most commonly from decreased mesenteric fat in the setting of significant weight loss, leads to compression of the third portion of the duodenum and resulting bowel obstruction. The patient underwent successful treatment with a novel approach: endoscopic placement of a gastrojejunostomy stent. CONCLUSIONS Food insecurity remains a wide-ranging public health issue that can have direct impact on the clinical outcomes of individuals. We describe SMA syndrome as a rare adverse outcome in a food insecure individual, adding to the growing list of health consequences associated with this condition. We also highlight endoscopic placement of a gastrojejunostomy stent as an emerging alternative to surgical treatment of SMA syndrome. The success of the procedure in this patient adds to the body of evidence supporting its efficacy and safety profile for this population.

Superior Mesenteric Artery Syndrome in an Adolescent Female with Anorexia Nervosa.

Superior mesenteric artery syndrome (SMAS) is a rare condition that develops from compression of the duodenum between the superior mesenteric artery (SMA) and abdominal aorta. SMAS is an atypical complication of restrictive eating disorders. The SMA is supported by adipose tissue to create an aortomesenteric angle that varies from 25-60 degrees. A reduction in adipose tissue causes narrowing of this angle, and SMAS develops when the aortomesenteric angle is narrow enough that it compresses the distal duodenum passing through. Patients present with small bowel obstructive symptoms. We report a severe case of SMAS in an adolescent female with anorexia nervosa who presented with acute and chronic symptoms of bowel obstruction. Awareness of the association between SMAS and restrictive eating disorders can help guide clinical decision-making and prevent delay of diagnosis and serious complications.

[A Case of Primary Jejunum Cancer Mimicking Superior Mesenteric Artery Syndrome].

In this report, we described a case of jejunum cancer that presented with abdominal pain and vomiting as chief complaints, which mimicked superior mesenteric artery syndrome. An elderly woman in her 70s was referred to our department for prolonged abdominal discomfort. Findings from CT and abdominal echo indicated that superior mesenteric artery syndrome may be responsible for jejunum cancer. Upper gastrointestinal endoscopy revealed a peripheral type 2 lesion in the upper jejunum. Upon biopsy, the patient was diagnosed with adenocarcinoma(papillary type). Surgical resection of the small intestine was performed. Although small intestinal cancer is a fairly rare disease, it should be considered a differential diagnosis. Comprehensive evaluations including medical history and imaging should be considered.

Nursing of a lactating patient with superior mesenteric artery syndrome: a case report.

Superior mesenteric artery syndrome (SMAS) involves duodenal obstruction caused by compression of the horizontal section of the duodenum between the superior mesenteric artery and abdominal aorta. Here, the experience of nursing a lactating patient with SMAS is summarized. Nursing care was performed according to a multiple therapy approach of treating the SMAS in addition to particular psychological factors that may be present during lactation. The patient underwent exploratory laparotomy under general anaesthesia, duodenal lysis, and abdominal aorta-superior mesenteric artery bypass with great saphenous vein grafting. The key nursing care included pain control, psychological care, positional therapy, observation and nursing care of fluid drainage and body fever, nutrition support and discharge health guidance. Through the above nursing methods, the patient was eventually able to return to a normal diet.