BACKGROUND: Obstruction of the third part of the duodenum (D3) is a very rare cause of gastric outflow obstruction. Rapid weight loss is the biggest risk factor. Patients seen in acute rehabilitation settings, not uncommonly, have a period of rapid weight loss. We report two cases of superior mesenteric artery (SMA) syndrome and review the literature. CLINICAL DETAILS: The patients presented differently, one with repeated, refractory autonomic dysreflexia and severe spasticity and one with nausea, abdominal discomfort, and vomiting. CT abdomen with contrast identified dynamic duodenal (D3) obstruction against the posterior structures by narrow angled SMA, gastric distension and, in one case, dilation of the left renal vein. Both patients responded well to optimizing nutrition in different ways. Surgery was successfully avoided. DISCUSSION: SMA syndrome is an atypical cause of high intestinal obstruction, frequently occurring in patients who have had rapid weight loss during spinal cord injury (SCI) rehabilitation. It may co-exist with left renal vein dilation "nutcracker phenomena". The associated neurogenic bowel dysfunction due to the nature of SCI could possibly contribute to delay in diagnosis. CONCLUSION: Clinicians should consider the risk of SMA syndrome in patients with SCI with rapid weight loss. Early diagnosis is possible by doing a CT abdomen with contrast and angiography if there is a high index of suspicion. SMA syndrome can be successfully treated by aggressive nutritional management. This may include total parenteral nutrition or feeding by a nasojejunal tube. Duodenojejunostomy could be required in refractory cases.
BACKGROUND: Obstruction of the third part of the duodenum (D3) is a very rare cause of gastric outflow obstruction. Rapid weight loss is the biggest risk factor. Patients seen in acute rehabilitation settings, not uncommonly, have a period of rapid weight loss. We report two cases of superior mesenteric artery (SMA) syndrome and review the literature. CLINICAL DETAILS: The patients presented differently, one with repeated, refractory autonomic dysreflexia and severe spasticity and one with nausea, abdominal discomfort, and vomiting. CT abdomen with contrast identified dynamic duodenal (D3) obstruction against the posterior structures by narrow angled SMA, gastric distension and, in one case, dilation of the left renal vein. Both patients responded well to optimizing nutrition in different ways. Surgery was successfully avoided. DISCUSSION: SMA syndrome is an atypical cause of high intestinal obstruction, frequently occurring in patients who have had rapid weight loss during spinal cord injury (SCI) rehabilitation. It may co-exist with left renal vein dilation "nutcracker phenomena". The associated neurogenic bowel dysfunction due to the nature of SCI could possibly contribute to delay in diagnosis. CONCLUSION: Clinicians should consider the risk of SMA syndrome in patients with SCI with rapid weight loss. Early diagnosis is possible by doing a CT abdomen with contrast and angiography if there is a high index of suspicion. SMA syndrome can be successfully treated by aggressive nutritional management. This may include total parenteral nutrition or feeding by a nasojejunal tube. Duodenojejunostomy could be required in refractory cases.
Entities:
Keywords:
Duodenum obstruction; Nutcracker; Spinal cord injury; Superior mesenteric artery; Weight loss