Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

Superior Mesenteric Artery Syndrome after Weight Loss from Dental Abscess Madison Battersby, OMS-III, Kristine Lombardozzi, MD Spartanburg Medical Center, VCOM-Carolinas, Spartanburg, SC Abstract

Discussion In a properly functioning habitus, the superior mesenteric artery branches from the descending aorta at the level of the L1 vertebra, the duodenum crosses the aorta at the level of the L3 vertebra, and the distal portion of the duodenum is suspended by the Ligament of Treitz. [5] SMA syndrome occurs when the acute angle at which the superior mesenteric artery branches off the aorta, also known as the aortomesenteric angle, and the distance between the aorta and superior mesenteric artery, also known as the aortomesenteric distance, are reduced. The normal aortomesenteric angle and distance are 28-65° and 10-34 mm respectively, however in SMA syndrome, these measurements can be reduced to 6-22° and 2-8 mm. [6] Body weight loss is the main cause of a reduced aortomesenteric angle and distance. Fat and lymphatic tissue surround the vasculature and lie between the superior mesenteric artery and duodenum to protect from compression, however reducing body weight decreases this padding and therefore increases the risk for occlusion. [2] Symptoms begin with vague abdominal pain, nausea, and vomiting and progress to abdominal distention, weight loss, and early satiety. Patients with SMA syndrome will experience worsening pain in the supine position, with relief while prone, in a knees to chest position, or lateral decubitus position. These symptoms can lead to cycles of nausea, decreased food intake, weight loss, and exacerbated symptoms from reduced fat content. [2,4] Imaging is obtained through either CT scan, abdominal ultrasound, or barium X-ray studies. CT scan is regarded as the imaging of choice for diagnosing SMA syndrome because both aortomesenteric angle and distance can be measured through the different axes.

Superior mesenteric artery (SMA) syndrome is an urgent condition wherein the third portion of the duodenum is compressed between the superior mesenteric artery and aorta leading to generalized symptoms of abdominal pain, nausea, and vomiting. CT imaging usually indicates a small bowel obstruction due to a reduction in fat pad mass protecting the duodenum. Therefore, conservative management with gastric decompression and nasogastric tube refeeding usually eliminate symptoms and restore nutritional status. If conservative management is insufficient, surgical intervention via laparoscopic duodenojejunostomy is indicated. Here we report a 20-year-old male patient presenting with SMA syndrome following recent significant weight loss successfully treated with conservative management. A 20-year-old male presented to the emergency department with a one-day history of severe right abdominal pain and vomiting. He endorsed tooth pain since removal of wisdom teeth and attributed his recent 35-pound weight loss to reduced appetite from the dental pain. The patient’s body mass index on admission was 14.5 kg/m 2 . CT scan of his abdomen and pelvis with IV contrast revealed a small bowel obstruction at the third part of the duodenum and a decreased aortomesenteric angle of 12 degrees. The clinical presentation of the patient along with CT imaging confirmed a diagnosis of SMA syndrome. A nasogastric (NG) tube was placed to relieve retained contents of the stomach and bilious output was observed. On day two of hospitalization, a prealbumin was measured at 17.3 mg/dL, normal values are 15.0 to 35.0 mg/dL, and tube feeds were initiated via the NG tube due to improved symptoms. [3] On day three, the NG tube was removed, and the patient was advanced to a regular diet. A small odontogenic abscess was seen on CT of the neck and the patient was prescribed antibiotics to resolve infection and improve the patient’s ability to eat. It is suspected that the persistent dental pain suppressed the patient’s appetite leading to reduced body weight and decreased intra-abdominal fat pad protecting the duodenum from compression by the superior mesenteric artery. In a follow up three weeks after initial admission, the patient had gained 6.9 kg (15 lb 6.4 oz) and had minimal residual abdominal pain. Case Presentation

References Clinicians must have a wide differential when addressing a patient presenting with abdominal pain allowing for SMA syndrome to be among the possible diagnoses. Due to the serious complications associated with undiagnosed SMA syndrome, it is important for clinicians to quickly rule out this condition whenever presented with a patient with recent weight loss, vomiting, and decreased appetite, especially in a young adult female. Prompt diagnosis and treatment, whether conservative or surgical, will reduce mortality and long-lasting complications in patients with SMA syndrome. The purpose of this paper is to display a common presentation of a rare pathologic process drawing awareness for clinicians to swiftly diagnose and treat the condition. Conservative treatment is usually sufficient to relieve compression of the duodenum and symptoms associated. Treatment includes gastric decompression via an NG tube along with refeeding, postural change in the left lateral decubitus or sitting position, and nutritional support through total parenteral nutrition (TPN) to increase weight and replenish the fat pad that protects the duodenum. Conservative management has a success rate of 71.3% and a recurrence rate of 15.8%. [1] If these modes of treatment fail, surgery is indicated. [5,7,8] According to recent data, a laparoscopic duodenojejunostomy is needed in 18.7% of cases with success rates between 80-100%. [1] Conclusion 1.Oka A, Awoniyi M, Hasegawa N, et al. Superior mesenteric artery syndrome: Diagnosis and management. World J Clin Cases . 2023;11(15):3369-3384. doi:10.12998/wjcc.v11.i15.3369 2.Ahmed AR, Taylor I. Superior mesenteric artery syndrome. Postgrad Med J . 1997;73(866):776 778. doi:10.1136/pgmj.73.866.776 3.Beck FK, Rosenthal TC. Prealbumin: a marker for nutritional evaluation [published correction appears in Am Fam Physician 2002 Dec 15;66(12):2208]. Am Fam Physician . 2002;65(8):1575 1578. 4.Van Horne N, Jackson JP. Superior Mesenteric Artery Syndrome. In: StatPearls . Treasure Island (FL): StatPearls Publishing; July 17, 2023. 5.Madhu B, Govardhan B, Krishna B. Cast syndrome. Oxf Med Case Reports . 2019;2019(4):omz025. Published 2019 Apr 29. doi:10.1093/omcr/omz025 6.Waheed KB, Shah WJ, Jamal A, et al. Superior mesenteric artery syndrome: An often overlooked cause of abdominal pain!. Saudi Med J . 2021;42(10):1145-1148. doi:10.15537/smj.2021.42.10.20210509 7.Oliva-Fonte C, Fernández Rey C, Pereda Rodríguez J, González-Fernández AM. Wilkie´s syndrome. Rev Esp Enferm Dig . 2017;109(1):62-63. 8.Karki B, Pun B, Shrestha A, Shrestha PS. Superior mesenteric artery syndrome. Clin Case Rep . 2020;8(11):2295-2297. Published 2020 Jul 16. doi:10.1002/ccr3.3118 9.Roy A, Gisel JJ, Roy V, Bouras EP. Superior mesenteric artery (Wilkie's) syndrome as a result of cardiac cachexia. J Gen Intern Med. 2005;20(10):C3-C4. doi:10.1111/j.1525-1497.2005.0201_2.x

Figure 2. “ Noncontrast computerized tomography scan of the abdomen showing dilated stomach and proximal duodenum. Compressed third part of the duodenum is seen between the calcified superior mesenteric artery and aorta. D, duodenum; Ao, aorta; S, stomach; SMA, superior mesenteric artery. ” [9]

Figure 1. Computed tomography image of the abdomen suggestive of Superior Mesenteric Artery Syndrome.

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2024 Research Recognition Day