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Superior Mesenteric Artery Syndrome Associated with Abdominal Aortic Aneurysm
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–2, 2017 Ó 2017 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2017.01.010
Visual Diagnosis in Emergency Medicine
SUPERIOR MESENTERIC ARTERY SYNDROME ASSOCIATED WITH ABDOMINAL AORTIC ANEURYSM Taft Franklin, MD and James L. Homme, MD Department of Emergency Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota Corresponding Address: Taft Franklin, MD, Department of Emergency Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905
masses. A computed tomography scan of the abdomen and pelvis with intravenous contrast showed marked distension of the stomach and first and second portions of the duodenum (Figures 1 and 2). In addition, we noted an AAA measuring 5.2 cm at its widest diameter (Figure 2). The aortomesenteric angle was approximately 8 (Figure 3). These imaging findings correlated with the history were consistent with SMA syndrome. The etiology in this case was multifactorial, involving weight loss caused by poor compliance with Celiac diet and AAA enlargement from 4.8 to 5.2 cm over 1 year. A gastrojejunostomy tube was placed for enteral feeding, with aneurysm repair deferred given the aneurysm size (<5.5 cm). The clinical course was complicated by refeeding syndrome, a bleeding gastric ulcer, and renal failure. Ultimately, duodenal stenting was required.
INTRODUCTION While superior mesenteric artery (SMA) syndrome is a rare cause of upper gastrointestinal obstruction, further duodenal compression by abdominal aortic aneurysm (AAA) is even less common. It has been described in case reports and case series, but it is unlikely to be considered during the emergency department workup of a patient with small bowel obstruction. The associated images allow the reader to visualize the pathophysiology of the entity described. CASE REPORT A 61-year-old man with history of coronary artery disease, a 4.8-cm AAA, and Celiac disease presented to the emergency department with 1 week of postprandial nausea and vomiting. This was associated with abdominal pain relieved by emesis consisting of undigested food. He described food avoidance during this time period and absence of bowel movement for 5 days. Further history revealed an unintentional 15-kg weight loss over the past 2 years. He had been poorly compliant with a gluten-free diet. The physical examination showed a cachectic male. His abdomen was nondistended with mild epigastric tenderness and no palpable
DISCUSSION Also known as Wilke syndrome, SMA syndrome is a rare cause of upper gastrointestinal obstruction. It was first described by Von Rokitansky in 1842, and later by others including Wilke in 1927 (1). It involves compression of the third part of the duodenum against the aorta or vertebral bodies by the SMA or its branches. A common contributing factor is rapid weight loss and subsequent
Reprints are not available from the authors.
RECEIVED: 22 September 2016; FINAL SUBMISSION RECEIVED: 4 January 2017; ACCEPTED: 5 January 2017 1
2
T. Franklin and J. L. Homme
Figure 1. Coronal computed tomography scan showing distended stomach (black asterisk) and proximal duodenum (white asterisk).
reduction of mesenteric fat stores, thereby decreasing the aortomesenteric angle (2). Several case reports have described further duodenal compression by an associated AAA (3). The mean aortomesenteric angle on abdominal
Figure 3. Sagittal computed tomography scan demonstrating abdominal aortic aneurysm and narrowed aortomesenteric angle (solid line). The arrow indicates the superior mesenteric artery and the arrowhead indicates the aorta.
computed tomography angiography has been shown to be 9 in patients with SMA compared with 44 in healthy controls (4). Treatment is primarily conservative, consisting of jejunal feeding to replenish mesenteric fat stores and decompress the duodenum. Surgical intervention consisting of gastrojejunostomy or duodenojejunostomy is reserved for failure of conservative management (2). In cases involving AAA, aneurysm repair has been used as a successful adjunct (3). REFERENCES
Figure 2. Axial computed tomography scan with 5.2-cm abdominal aortic aneurysm. The arrow indicates the superior mesenteric artery, the arrowhead indicates the aorta, the black asterisk indicates the stomach, and the white asterisk indicates the proximal duodenum.
1. Welsch T, Bu¨chler MW, Kienle P. Recalling superior mesenteric artery syndrome. Dig Surg 2007;24:149–56. 2. Mathenge N, Osiro S, Rodriguez II, Salib C, Tubbs RS, Loukas M. Superior mesenteric artery syndrome and its associated gastrointestinal implications. Clin Anat 2013;27:1244–52. 3. Pal A, Cameron A. Superior mesenteric artery syndrome in association with an abdominal aortic aneurysm. Ann R Coll Surg Engl 2009; 91:W6–7. 4. Konen E, Amitai M, Apter S, et al. CT angiography of superior mesenteric artery syndrome. AJR Am J Roentgenol 1998;171: 1279–81.
http://dx.doi.org/10.1016/j.jemermed.2017.01.010
Visual Diagnosis in Emergency Medicine
SUPERIOR MESENTERIC ARTERY SYNDROME ASSOCIATED WITH ABDOMINAL AORTIC ANEURYSM Taft Franklin, MD and James L. Homme, MD Department of Emergency Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota Corresponding Address: Taft Franklin, MD, Department of Emergency Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905
masses. A computed tomography scan of the abdomen and pelvis with intravenous contrast showed marked distension of the stomach and first and second portions of the duodenum (Figures 1 and 2). In addition, we noted an AAA measuring 5.2 cm at its widest diameter (Figure 2). The aortomesenteric angle was approximately 8 (Figure 3). These imaging findings correlated with the history were consistent with SMA syndrome. The etiology in this case was multifactorial, involving weight loss caused by poor compliance with Celiac diet and AAA enlargement from 4.8 to 5.2 cm over 1 year. A gastrojejunostomy tube was placed for enteral feeding, with aneurysm repair deferred given the aneurysm size (<5.5 cm). The clinical course was complicated by refeeding syndrome, a bleeding gastric ulcer, and renal failure. Ultimately, duodenal stenting was required.
INTRODUCTION While superior mesenteric artery (SMA) syndrome is a rare cause of upper gastrointestinal obstruction, further duodenal compression by abdominal aortic aneurysm (AAA) is even less common. It has been described in case reports and case series, but it is unlikely to be considered during the emergency department workup of a patient with small bowel obstruction. The associated images allow the reader to visualize the pathophysiology of the entity described. CASE REPORT A 61-year-old man with history of coronary artery disease, a 4.8-cm AAA, and Celiac disease presented to the emergency department with 1 week of postprandial nausea and vomiting. This was associated with abdominal pain relieved by emesis consisting of undigested food. He described food avoidance during this time period and absence of bowel movement for 5 days. Further history revealed an unintentional 15-kg weight loss over the past 2 years. He had been poorly compliant with a gluten-free diet. The physical examination showed a cachectic male. His abdomen was nondistended with mild epigastric tenderness and no palpable
DISCUSSION Also known as Wilke syndrome, SMA syndrome is a rare cause of upper gastrointestinal obstruction. It was first described by Von Rokitansky in 1842, and later by others including Wilke in 1927 (1). It involves compression of the third part of the duodenum against the aorta or vertebral bodies by the SMA or its branches. A common contributing factor is rapid weight loss and subsequent
Reprints are not available from the authors.
RECEIVED: 22 September 2016; FINAL SUBMISSION RECEIVED: 4 January 2017; ACCEPTED: 5 January 2017 1
2
T. Franklin and J. L. Homme
Figure 1. Coronal computed tomography scan showing distended stomach (black asterisk) and proximal duodenum (white asterisk).
reduction of mesenteric fat stores, thereby decreasing the aortomesenteric angle (2). Several case reports have described further duodenal compression by an associated AAA (3). The mean aortomesenteric angle on abdominal
Figure 3. Sagittal computed tomography scan demonstrating abdominal aortic aneurysm and narrowed aortomesenteric angle (solid line). The arrow indicates the superior mesenteric artery and the arrowhead indicates the aorta.
computed tomography angiography has been shown to be 9 in patients with SMA compared with 44 in healthy controls (4). Treatment is primarily conservative, consisting of jejunal feeding to replenish mesenteric fat stores and decompress the duodenum. Surgical intervention consisting of gastrojejunostomy or duodenojejunostomy is reserved for failure of conservative management (2). In cases involving AAA, aneurysm repair has been used as a successful adjunct (3). REFERENCES
Figure 2. Axial computed tomography scan with 5.2-cm abdominal aortic aneurysm. The arrow indicates the superior mesenteric artery, the arrowhead indicates the aorta, the black asterisk indicates the stomach, and the white asterisk indicates the proximal duodenum.
1. Welsch T, Bu¨chler MW, Kienle P. Recalling superior mesenteric artery syndrome. Dig Surg 2007;24:149–56. 2. Mathenge N, Osiro S, Rodriguez II, Salib C, Tubbs RS, Loukas M. Superior mesenteric artery syndrome and its associated gastrointestinal implications. Clin Anat 2013;27:1244–52. 3. Pal A, Cameron A. Superior mesenteric artery syndrome in association with an abdominal aortic aneurysm. Ann R Coll Surg Engl 2009; 91:W6–7. 4. Konen E, Amitai M, Apter S, et al. CT angiography of superior mesenteric artery syndrome. AJR Am J Roentgenol 1998;171: 1279–81.