Dr. Terencia, Dr. Dr. Naveen Viswanath(paediatric surgery), Dr. C Jayakumar, AIMS, KOCHI
Eleven year old presented with abdominal pain and multiple episodes of non-bilious vomiting of 12 days duration. Outside hospital USG abdomen showed dilated stomach suggestive of gastric outlet obstruction(GOO) and CT scan showed GOO with secondary compression of confluence of superior mesenteric vein/superior mesenteric artery and left renal vein. Upper GI scopy showed compression narrowing at D3 suggestive of GOO.
She was kept NPO and referred to AIMS
Child had an uneventful perinatal history
Growth parameters were within normal limits.
At examination vitalsandPICCLE were normal.
GI examination revealed soft abdomen which was non tender and bowel sounds were appreciated
DIFFERENTIALS-
1. Gastric outlet obstruction
2. Small bowel obstruction
3. Intestinal Malrotation
4. Pancreatitis
5. Gastroparesis
6. Functional GI disorders
7. Chronic intestinal pseudo obstruction
8. Non ulcer dyspepsia
Labs TC-6.9K, N-64%, L-26%
CRP. LFT, RFT and URE were normsl . S.K+-2.9 meq/L low was corrected with parenteral potassium supplements.
Pre-op serology wnegativec
Upper GI endoscopy done at AIMS showed normal oesophagus and large amount of bilious fluid was suctioned out . Guide wire was passed and with some difficulty through D2, hence Freka 12 Fr NJ tube was placed into the jejunum and secured and feeds were started via the same.
CECT abdomen done outside reviewed and suggested that it showed hugely dilated fluid filled stomach dipping down into the pelvis. Dilated fluid filled 1st and 2nd parts of the duodenum with abrupt change in calibre at the D3. Narrowed aortomesenteric angle around 13 degree with aortomesenteric distance of 2mm was noted. Distal bowel loops appeared collapsed. Hence findings were consistent with Superior mesenteric artery syndrome causing obstruction at D3 duodenal level with hugely dilated stomach and proximal duodenum.
Hence gastro jejunostomy was done. Operative findings showed grossly dilated stomach and duodenum. Oral feeds were restarted on post op day six and was tolerated well. At the time of discharge she was clinically stable and was taking feeds well.
Superior mesenteric artery syndrome is an unusual cause of proximal intestinal obstruction.
Other names are Cast syndrome, Wilkie syndrome, arteriomesenteric duodenal obstruction, and chronic duodenal ileus.
In this third part of the duodenum due to loss of intervening pad of fat narrowing of the space between the superior mesenteric artery and aorta and is seen
Diagnosis is challenging as SMA syndrome is uncommon, and symptoms can be nonspecific. The diagnosis is established in patients with clinical features that suggest duodenal obstruction and noninvasive imaging that demonstrates an abnormal angle between the aorta and the superior mesenteric artery.