Tratamento cirúrgico da síndrome da artéria mesentérica superior em paciente idosa / Surgical treatment of mesenteric superior artery syndrome in an older woman

A síndrome da artéria mesentérica superior (SAM), ou síndrome de Wilkie, é uma afecção rara que acomete geralmente indivíduos jovens do sexo feminino. Caracterizada pela obstrução parcial ou completa do duodeno devido à compressão pela artéria mesentérica superior anteriormente, e pela aorta, posteriormente. Apresentamos um caso não usual de SAM, em paciente idosa, diagnosticado através de história clínica e imagem tomográfica característica. Indicou-se manejo cirúrgico de derivação jejunal e anastomose com duodeno acima da obstrução, na ciência do risco do procedimento. A paciente apresentou excelente evolução e encontra-se assintomática. O diagnóstico precoce, através de uma anamnese adequada e uso dos critérios radiológicos já definidos em literatura, podem afetar positivamente o desfecho dos pacientes portadores em qualquer faixa etária. (AU)

Superior mesenteric artery syndrome (SMAS), or Wilkie syndrome, is a rare condition that usually affects young women. It is characterized by partial or complete obstruction of the duodenum due to compression by the superior mesenteric artery anteriorly and by the aorta posteriorly. We report an unusual case of SMAS in an older woman diagnosed using clinical history and tomographic imaging. Surgical management consisting of jejunal shunt and anastomosis with duodenum above the obstruction was indicated despite the risk of the procedure. The outcome was excellent, and the patient is asymptomatic. Early diagnosis using adequate anamnesis and radiological criteria defined in the literature may positively influence the outcome of patients from any age group. (AU)

Síndrome pinzamiento mesentérico: a propósito de un caso de hiperemesis / Superior mesenteric aartery syndrome: in relation to a case of hypermesis

INTRODUCCIÓN: El Síndrome de Arteria Mesentérica (SAMS) o Pinzamiento Mesentérico es un trastorno adquirido poco frecuente. Su característica principal es la obstrucción de origen vascular de la tercera porción duodenal, entre la arteria mesentérica superior y la aorta abdominal. CASO CLÍNICO: Mujer de 42 años de edad con antecedentes de trastorno depresivo, colecistectomizada en 1994 y múltiples hospitalizaciones por hiperemesis desde 1995 con estudios no concluyentes. Ingresó en diciembre de 2011 por vómitos alimentarios, con gran compromiso nutricional. Se le realizaron múltiples estudios que descartaron enfermedades reumatológicas, hepáticas e infecciosas. Entre los estudios imagenológicos, la endoscopía digestiva alta mostró esofagitis congestiva leve y gastritis crónica antral, al igual que todas las endoscopias previas. En la radiografía seriada esófago-gastroduodenal se observa severo reflujo gastroesofágico,y compresión compatible con pinzamiento. La tomografía computarizada de abdomen y pelvis mostraba el estómago de mayor tamaño que lo habitual y el duodeno presentaba nuevamente esta compresión compatible con pinzamiento. En base a estos últimos hallazgos imagenológicos, y luego de descartar variados diagnósticos diferenciales se planteó un SAMS y se decidió realizar bypass duododenoyeyunal, con buena evolución posterior. DISCUSIÓN: El diagnostico de SAMS es muchas veces de exclusión, basado en la clínica y la imagenología abdominal que descarta otros cuadros clínicos. En este caso se tiene el antecedente de múltiples hospitalizaciones sin diagnóstico concluyente. Finalmente por la larga evolución del cuadro se decide una resolución quirúrgica.

INTRODUCTION: The Superior Mesenteric Artery Syndrome (SMAS) is an uncommon acquired disorder. The main characteristic is the obstruction due to compression of the third portion of the duodenum, between the superior mesenteric arthery and the abdominal aorta. CLINICAL CASE: 42-year-old female patient with a record of depressive disorder, cholecystectomyperformed in 1994 and multiple hospitalizations due to hyperemesissince 1995, with inconclusive studies. Was admitted to the hospital on December 2011 because to alimentary vomit associated with great nutritional compromise. Multiple exams were performed to discard rheumatologic, hepatic and infectious diseases. The imaging test showed high digestive endoscopy with mild esophagitis and antral chronic gastritis, as in previous endoscopies. Stomach-esophagus-duodenum radiography with gastroesophageal reflux and extrinsic compression of the duodenum. Abdominal and pelvic computed tomography revealed a larger than usual stomach’s size and a compression in the duodenum compatible with pinching. Based on these last results and after we discard other options, we diagnosed a superior mesenteric artery syndrome and it was decided to perform a duodenojejunal bypass, with favorable evolution. DISCUSSION: The diagnosis of SMAS many times is made by exclusion based on the clinic and the abdominal images, discarding other pathologies. In this case, multiple hospitalizations with inconclusive diagnostics led to performing several tests for a variety of illnesses. Finally, based on the large evolution of the case it was decided a surgical resolution.

Wilkie’s syndrome: review of eight cases / Wilkie’s syndrome: review of eight cases.

BACKGROUND: The superior mesenteric artery (SMA) syndrome is a rare entity presenting with upper gastrointestinal tract obstruction and abrupt weight loss. Usually seen in tall individual with low bod mass index (BMI), the weight loss may be primary or secondary to a systemic disease or to the syndrome itself Compression of the duodenum between the abdominal aorta and the superior mesenteric artery due to loss of the duodenal pad of fat causes the obstruction. Early recognition prevent complications. Imaging and endoscopy is diagnostic. Aorto-mesenteric angle and SMA aorta distance is lower than 22 degree and eight millimeter respectively. If nutritional support fails, surgery is required (e.g. guodeno-jejunostomy). Studies to determine the optimal methods of diagnosis and treatment, especially in a suburban hospitals with limited expertise are essential. CASE REPORT: We retrospectively evaluated 8 cases presented over three years. Six (75

) patients were males, age ranged from 19 to 70 years and weight from 40 to 55 kg. The mean BMI was 18.7 kg/ m2 (range 16.42 to 25.11 kg/m2). Mean weight loss before diagnosis was 9.88 kg (range 6 to 12 kg). Symptoms developed between 8 to 180 days (median 12 days). Commonest presentation was epigastric pain, vomiting and nausea. Four patients had pre-morbid conditions and the syndrome was idiopathic in the other 4. Median aorto-mesentric angle was 16.5 degree and SMA-aorta distance was 5.15 mm. Four patients required operation. The rest improved on conservative treatment. CONCLUSION: Early recognition, institution of the appropriate conservative measures and timely selection of a definite surgical method are critical to prevent severe complications and death.

Spontaneous Isolated Superior Mesenteric Artery Dissection Mimicking Superior Mesenteric Artery Syndrome / 대한소화기학회지

No abstract available.

Optimal Duration of Medical Treatment in Superior Mesenteric Artery Syndrome in Children

The aim of this study was to investigate the outcome, and optimal duration of medical treatment in children with superior mesenteric artery syndrome (SMAS). Eighteen children with SMAS were retrospectively studied. The data reviewed included demographics, presenting symptoms, co-morbid conditions, clinical courses, nutritional status, treatments, and outcomes. The three most common symptoms were postprandial discomfort (67.7%), abdominal pain (61.1%), and early satiety (50%). The median duration of symptoms before diagnosis was 68 days. The most common co-morbid condition was weight loss (50%), followed by growth spurt (22.2%) and bile reflux gastropathy (16.7%). Body mass index (BMI) was normal in 72.2% of the patients. Medical management was successful in 13 patients (72.2%). The median duration of treatment was 45 days. Nine patients (50%) had good outcomes without recurrence, 5 patients (27.8%) had moderate outcomes, and 4 patients (22.2%) had poor outcomes. A time limit of >6 weeks for the duration of medical management tended to be associated with worse outcomes (P=0.018). SMAS often developed in patients with normal BMI or no weight loss. Medical treatment has a high success rate, and children with SMAS should be treated medically for at least 6 weeks before surgical treatment is considered.

A Case of Gastric Emphysema in Anorexia Nervosa Presenting as Acute Gastric Distension / 대한소화기학회지

Gas within the gastric wall is an alarming finding and a rare condition. Clinically, this condition is divided into two entities; Gastric emphysema and emphysematous gastritis. These two diseases should be differentiated because they are characterized by different clinical symptoms, possible etiology, treatment and prognosis. While emphysematous gastritis is a severe condition with high mortality, gastric emphysema is asymptomatic and usually has benign course. Rarely, anorexia nervosa and bulimia nervosa have been discribed to be associated with acute gastric distension and duodenal obstruction induced by superior mesentery artery syndrome. So, gastric emphysema could be accompanied by acute gastric distension induced by anorexia nervosa. We report a rare case of gastric emphysema in a patient with anorexia nervosa presenting as superior mesenteric artery syndrome with relevant literatures. In this case, the gastric emphysema was improved without surgical intervention after nasogastric tube for decompression and feeding insertion in the fourth portion of the duodenum.

Superior mesenteric artery compression syndrome - case report

Superior mesenteric artery syndrome is an entity generally caused by the loss of the intervening mesenteric fat pad, resulting in compression of the third portion of the duodenum by the superior mesenteric artery. This article reports the case of a patient with irremovable metastatic adenocarcinoma in the sigmoid colon, that evolved with intense vomiting. Intestinal transit was carried out, which showed important gastric dilation extended until the third portion of the duodenum, compatible with superior mesenteric artery syndrome. Considering the patient's nutritional condition, the medical team opted for the conservative treatment. Four months after the surgery and conservative measures, the patient did not present vomiting after eating, maintaining previous weight. Superior mesenteric artery syndrome is uncommon and can have unspecific symptoms. Thus, high suspicion is required for the appropriate clinical adjustment. A barium examination is required to make the diagnosis. The treatment can initially require gastric decompression and hydration, besides reversal of weight loss through adequate nutrition. Surgery should be adopted only in case of clinical treatment failure. (AU)

A síndrome da artéria mesentérica superior é uma entidade clínica causada geralmente pela perda do tecido adiposo mesentérico, resultando na compressão da terceira porção do duodeno pela artéria mesentérica superior. Esse artigo relata o caso clínico de uma paciente portadora de adenocarcinoma de cólon sigmoide metastático irressecável, que evoluiu com vômitos incoercíveis. Realizou-se, então, trânsito intestinal que evidenciou dilatação gástrica importante, que se prolongava até a terceira porção duodenal, quadro radiológico compatível com pinçamento da artéria mesentérica superior. Diante da condição nutricional da paciente, foi optado por iniciar medidas conservadoras (porções alimentares pequenas e mais frequentes, além de decúbito lateral esquerdo após as refeições). Quatro meses após a cirurgia e as medidas conservadoras, a paciente não apresentava mais vômitos pós-prandiais, nem emagrecimento. A síndrome da artéria mesentérica inferior é incomum e os sintomas podem ser inespecíficos. Sendo assim, um índice elevado de suspeita é exigido no ajuste clínico apropriado. O diagnóstico é feito, habitualmente, através de exame radiológico contrastado. O tratamento pode, inicialmente, exigir a descompressão gástrica e a reposição volêmica, além da reversão da perda de peso com nutrição adequada. A cirurgia deve ser reservada para os casos de falha do tratamento clínico. (AU)

A Case of Superior Mesenteric Artery Syndrome Caused by Anorexia Nervosa / 대한소화기학회지

Superior mesenteric artery (SMA) syndrome is a rare disorder, characterized by compression of the third segment of the duodenum by the mesenteric artery at the level of the SMA, resulting in duodenal dilatation. Precipitating factors of the SMA syndrome include prolonged bed rest, weight loss, abdominal surgery, and increased lordosis of the spine. We report a case of SMA syndrome caused by anorexia nervosa in a 15-year-old adolescent girl. CT and an upper gastrointestinal contrast series revealed partial obstruction of the third portion of duodenum and decreased aortomesenteric distance. The patient's symptoms were successfully treated with total parental nutrition and psychiatric treatment including supportive, cognitive behavioral therapy and antidepressant medication. This case shows that SMA syndrome is an unusual gastrointestinal complication that may occur in patients with anorexia nervosa.

Acute and chronic mesenteric ischemia: MDCT findings / Isquemia mesentérica aguda e crônica: achados tomográficos

Mesenteric ischemia is caused by a reduction in mesenteric blood flow. It can be divided into acute and chronic, based upon the rapidity and the degree to which the blood flow is compromised. The authors retrospectively reviewed 22 cases of mesenteric ischemia, diagnosed by multidetector computed tomography (MDCT) in our service, and confirmed by surgery or clinical follow-up. The frequency of the diagnostic findings of chronic and acute mesenteric ischemia was evaluated. The improvement of three-dimensional (3D) MDCT allows accurate assessment of mesenteric vessels. Therefore, it demonstrates changes in ischemic bowel segments helpful in determining the primary cause of the disease, and can identify the complications in patients with acute and chronic mesenteric ischemia.

A isquemia mesentérica é causada pela redução do fluxo sanguíneo mesentérico. Essa patologia pode ser dividida em aguda e crônica, baseada na rapidez e no grau em que o fluxo sanguíneo está sendo comprometido. Os autores retrospectivamente revisaram 22 casos de isquemia mesentérica, diagnosticados por tomografia computadorizada com mutidetectores (TCMD) em nosso serviço, e confirmados por cirurgia ou seguimento clínico. Os achados diagnósticos de isquemia aguda e crônica e sua frequência foram avaliados. Os avanços na TCMD 3D (tridimensional) permitiram o acesso detalhado aos vasos mesentéricos. Além disso, é possível demonstrar alterações nos segmentos intestinais, auxiliando na identificação da causa primária da doença e podendo identificar as complicações associadas a isquemia mesentérica e crônica.

Síndrome de Wilkie: presentación de un caso / Superior artery syndrome: Wilkie's Syndrome: case report

El síndrome de Wilkie o síndrome de la arteria mesentérica superior es una rara condición médica originada por la compresión vascular de la tercera porción duodenal entre la arteria mesentérica superior y la aorta abdominal. Los factores predisponentes incluyen desórdenes alimenticios, enfermedades catabúlicas severas, enfermedades de la columna vertebral, trauma severo y estados postoperatorios. El síntoma clinico típico es el dolor epigástrico, intermitente, acompañado de vómitos voluminosos. La duodenografía hipotónica con bario constituye el gold standard para su estudio, pero actualmente la tomografía computada con multidetectores ofrece mayores ventajas diagnósticas. El tratamiento quirúrgico incluye duodenoyeyunostomía, gastroyeryunostomía o lisis del ligamento de Treitz, que pueden realizarse por vía convencional o laparoscópica.

Wilkie's syndrome or superior mesenteric artery syndrome is a rare medical condition caused by vascular compression of the third duodenal portion between the superior mesenteric artery and abdominal aorta. The predisposing factors include eating disorders, severe catabolic diseases, and diseases of the spine, severe trauma and postopertive states. The typical symptom is intermittent epigastric pain, accompanied by vomiting. The hypotonic duodenography with barium is the gold standard for study, but now with the multidetector row CT scan offers greater diagnostic advantages. Surgical treatment includes duodenojejunostomy, gastrojejunostomy and lysis of the ligament of Treitz, which may be performed conventional or laparosocopic.

Síndrome de la arteria mesentérica superior (síndrome de Wilkie): caso clínico / Superior mesenteric artery syndrome (Wilkie syndrome): case report

El síndrome de la arteria mesentérica superior (síndrome de Wilkie) es una causa poco frecuente de obstrucción duodenal de origen vascular. Se asocia con situaciones que disminuyen elángulo entre la arteria mesentérica superior y la aorta (compásaortomesentérico) secundarias a pérdida de grasa retroperitoneal (descenso brusco de peso o caquexia) o procedimientos que determinan hiperextensión dorsal, especialmente enpostquirúrgicos de cirugía correctora de escoliosis. Clínicamente, se manifiesta por obstrucción intestinal alta. El diagnósticoes radiológico y el tratamiento es inicialmente médico. El tratamiento quirúrgico se reserva para casos refractarios. Se describe el caso de un paciente de 18 años con síndrome de Wilkie, secundario a cirugía correctora de escoliosis dorsolumbar. Con la sospecha clínica se realiza seriada gastroduodenal que confirma el diagnóstico. Inicia tratamiento médico con dieta hipercalórica fraccionada y medidas posturales con buena respuesta.

Síndrome de la arteria mesentérica superior: presentación de un caso y revisión de la literatura / Superior mesenteric artery syndrome: a case report and literature review

Se realizó una revisión bibliográfica sobre el síndrome de la arteria mesentérica superior y se presenta un caso, en el que junto a un megaduodeno sintomático se hallaron anomalías de la arteria mesentérica y anomalías congénitas del ángulo duodeno yeyunal y de rotación intestinal anómala. De la revisión bibliográfica realizada se precisa lo poco frecuente del síndrome, negado por algunos autores, y se afirma que no hay tal pinzamiento sino la combinación de factores, entre los que predominan anomalías congénitas(AU)

A bibliographic review on the superior mesenteric artery syndrome was made. It was reported a case with a symptomatic megaduodenum that also presented abnormalities of the mesenteric artery and congenital anomalies of the duodenojejunal angle and of intestinal malrotation. According to the bibliographic review, it was determined that it is a rare syndrome that is denied by some authors, and that there is no such impingement, but the combination of factors, among which the congenital anomalies prevail(AU)

Superior mesenteric artery syndrome: case report.

Superior mesenteric artery (SMA) syndrome is a rare acquired disorder in which acute angulation of SMA causes compression of the third part of the duodenum between the SMA and the aorta, leading to obstruction. Loss of fatty tissue as a result of a variety of debilitating conditions is believed to be the etiologic factor causing the acute angulation. We report a case of 30 years old lady who presented with postprandial abdominal pain at the epigastric region, colic type without radiation accompanied by nausea, postprandial vomiting and weight loss. Esophageal gastric series revealed an abrupt interruption in the contrast medium flow at the level of the junction of third portion (midpart) of the duodenum in barium studies. Adiverticula is noted just proximal to the site of obstruction. High resolution ultrasound and color Doppler sonography showed narrowing of the aortomesenteric angle to 220. Duodenojejunostomy was performed in the patient. Unfortunately the patient later was admitted in the hospital for refractory gastroparesis associated with superior mesenteric artery syndrome. Although open and laparoscopic duodenojejunostomy have been described as the best surgical treatment options for Wilkie's syndrome, but further attention is needed to the management of patients with refractory symptoms of gastroparesis after corrective surgery.

Anorexia nervosa versus superior mesenteric artery syndrome in a young woman: Case report and literature review

Anorexia nervosa is an eating disorder seen mainly in females. It is one of the differential diagnoses of a rare surgical syndrome called superior mesenteric artery syndrome. Differentiation between them is usually difficult. We report here a case of superior mesenteric artery syndrome with later diagnosis of anorexia nervosa. Patient did not respond to surgical treatment. Indicative factors to suspect anorexia nervosa are discussed with literature review

Superior mesentric artery compression syndrome.

Superior Mesenteric Artery Syndrome is an atypical cause of high intestinal obstruction seen frequently in patients with rapid weight loss or immobilization in a body cast (\also called CAST Syndrome). The SMA impinges on the third part of the duodenum immediately after originating from the anterior aspect of aorta, making an abnormally narrow angle with the later. Intestinal obstruction results causing characteristic symptoms like postprandial epigastric pain, eructations, fullness and vomiting. Here we report such a case of SMA syndrome in a patient with history of rapid loss of weight.

Incomplete duodenal obstruction in a newborn.

A case of newborn with incomplete duodenal obstruction caused by superior mesenteric artery syndrome has been presented with this report. A full term, 1-day-old baby girl was referred to our hospital because of recurrent bilious vomiting since birth and upper gastrointestinal barium study revealed the incomplete obstruction at the 3rd part of the duodenum with a vertical abrupt cutoff. The diagnosis of superior mesenteric artery syndrome was made with ultrasonography and duodenojejunostomy was carried out. Although it is extremely rare, superior mesenteric artery syndrome should also be considered as one of the rare cause of incomplete duodenal obstruction in newborn period.

Superior mesenteric artery syndrome: an uncommon cause of intestinal obstruction; report of two cases and review of literature

Superior mesenteric artery [SMA] syndrome is caused by the compression of the third part of the duodenum leading to upper intestinal obstruction which is aggravated when the patient is lying in the supine position. Predisposing factors include rapid weight loss, application of a body cast after spinal surgery, prolonged recumbency, and abnormal position of the ligament of Treitz. Diagnosis may be difficult but can be confirmed by upper gastrointestinal contrast studies. Treatment is mainly conservative and if failed, surgical intervention is warranted. We report two children who were diagnosed with SMA syndrome and discuss the clinical picture, ways of diagnosis and methods of treatment

Superior Mesenteric Artery Syndrome / 대한소화기학회지

No abstract available

Síndrome do pinçamento aorto-mesentérico: relato de caso / Superior mesenteric artery syndrome: case report

A Sínsdrome da Artéria Mesentérica Superior (SAMS), também chamada de Síndrome de Wilkie, é uma rara entidade, que tem sintomatologia caracterizada por dor epigátrica, saciedade precoce, desconforto pósprandial (fullness), náuseas, vômitos e emagrecimento. Essa sintomatologia deve-se a uma obstrução ao nível da terceira porção do duodeno, ocasionada pelo seu pinçamento entre as artérias aorta abdominal e mesentérica superior, as quais apresentam diminuição do ânfgulo formado entre elas (menor de 30 graus). Os autores relatam um caso de SAMS, em uma paceinte de 49 anos, o diagnóstico foi feito pela arteriografia, que mostrou um ângulo muito fechado entre ambas as artérias, associado a uma dilatação duodenal. O tratamento realizado neste caso foi uma gastrojejunostomia, uma vez que a paciente já havia sido submet5ida previamente a uma gastrectomia Billroth. A evoluçxão da paciente mostra-se satisfatória, até o presente momento