A Rare Case Of Proximal Intestinal Obstruction From Superior Mesenteric Artery Syndrome

INTRODUCTION: Superior mesenteric artery (SMA) syndrome is a rare disorder that is characterized by compression of the third portion of the duodenum due to narrowing of the angle between the SMA and the aorta. Patients typically present with intermittent postprandial epigastric pain, nausea, and bilious vomiting. We report a case of a 25-year-old female who presents with symptoms of intestinal obstruction, diagnostic evaluation revealing SMA syndrome, and successful duodeno-jejunostomy procedure. CASE DESCRIPTION/METHODS: A 25-year-old female history of cholecystectomy presented with worsening symptoms of nausea, intractable vomiting, postprandial epigastric pain, and twenty pound weight loss for 2 years. She had multiple hospitalizations and extensive gastrointestinal work-up in the past without any identifiable cause of her symptoms. Physical exam, labs, CT abdomen and pelvis, EGD, colonoscopy, and PillCam endoscopy were benign. CT angiography of abdomen and pelvis demonstrated a decreased aorta-superior mesenteric artery angle of 9.1 degrees (normal 38 degrees to 65 degrees) with aorta- superior mesenteric distance of 5.1 mm (normal 10 to 28 mm), and compression of the third part of duodenum, confirming the diagnoses of SMA syndrome. She was initially managed conservatively with duodenal and gastric decompression via NG tube, fluid and electrolyte correction, body positioning, proton pump inhibitors, and nutritional support. Unfortunately, the patient had no improvement in her symptoms and subsequently required duodeno-jejunostomy. Upon completion of the procedure, the patient had complete resolution of her presenting symptoms. DISCUSSION: The diagnosis of SMA syndrome requires a high clinical suspicion in order to obtain abdominal angiography in patients with persistent symptoms despite negative endoscopic and conventional radiographic findings. Diagnosis requires an aorto-mesenteric angle between 6-22 degrees and an aorto-mesenteric distance between 2-8 mm on CT angiography. Patients should initially be managed with conservative therapy. However, if symptoms fail to improve or increase in severity, surgery is the definitive treatment. Surgical options include duodeno-jejunostomy, gastro-jejunostomy, and Strong’s procedure. Duodeno-jejunostomy is the procedure of choice, as it carries a 90% success rate.