Superior Mesenteric Artery Syndrome

Clinical History

We performed an abdominal CT examination on a 35 year old female patient complaining of epigastric pain and sense of fullness, nausea, eructation and postprandial discomfort.

Imaging Findings

CT scanning was performed after oral and intravenous contrast administration and demonstrated dilated first and second portion of duodenum and compression of third portion of duodenum and left renal vein between aorta and superior mesenteric artery. Aortomesenteric distance measured 4mm. In sagittal reconstruction aortomesenteric angle was less than 22°.

Discussion

Superior mesenteric artery syndrome, also known as Wilkie's syndrome, is a rare condition in which narrowing of the space between aorta and superior mesenteric artery causes compression of the third portion of duodenum. It is thought to be secondary to excessive weight loss (cancer, AIDS, malabsorption, drug use, anorexia nervosa) which leads to significant reduction of intraabdominal adipose tissue[1]. The condition has also been found to be triggered by certain types of surgical procedures such as esophagectomy and surgical correction of spinal deformities[1]. Clinical manifestations include postprandial abdominal pain, nausea, vomiting, early satiety and eructation. The concomitant compression of left renal vein is known as nutcracker phenomenon or left renal vein entrapment. The term nutcracker syndrome is used when left renal vein entrapment is associated to symptoms such as hematuria and left flank pain[2].
Plain and barium abdominal radiograph may demonstrate a dilated fluid and gas filled stomach due to duodenal obstruction and delayed gastroduodenal emptying. Important CT findings suggestive of superior mesenteric artery syndrome include compression of the third portion of duodenum, dilated first and second portion of duodenum, an aortomesenteric distance less than 10mm (usually 2-8mm), and an aortomesenteric angle less than 22°[3].
Treatment options are surgical or non surgical. Nutritional therapy aiming weight gain may relief symptoms in some patient by widening the aortomesenteric space, thus alleviating duodenal obstruction[4]. When conservative therapy fails surgical treatment may be required. Laparoscopic duodenojejunostomy is considered the prefered procedure[5].

Differential Diagnosis List

Final Diagnosis

Superior mesenteric artery syndrome

URL:	https://www.eurorad.org/case/11105
DOI:	10.1594/EURORAD/CASE.11105
ISSN:	1563-4086