Dunbar's syndrome and superior mesenteric artery's syndrome: a rare association

Supradiaphragmatic origin of the celiac trunk leading to median arcuate ligament syndrome with superior mesenteric artery involvement

Median arcuate ligament (MAL) syndrome (MALS) is a rare condition caused by compression of the celiac artery by the MAL. Symptoms include abdominal pain, nausea, and weight loss. Rarely, the MAL can compress both the celiac artery and the superior mesenteric artery (SMA). We describe the case of a young man with MALS involving the celiac artery and SMA. Laparoscopic release of the MAL was performed, and the patient had resolution of his symptoms at 6 months of follow-up. A review of the literature identified only six cases of MALS involving the SMA and celiac artery, making this a rare occurrence.

A man with the rare simultaneous combination of three abdominal vascular compression syndromes: median arcuate ligament syndrome, superior mesenteric artery syndrome, and nutcracker syndrome

Median arcuate ligament syndrome and superior mesenteric artery syndrome are well-known abdominal compression syndromes, the coexistence of which is rarely described in literature. In addition, due to the common pathogenesis, anterior nutcracker syndrome may occur simultaneously to superior mesenteric artery syndrome. To our knowledge, this is the first case reporting combination of these 3 syndromes detected with ultrasound, Computed Tomography and upper gastrointestinal fluoroscopic exam. A 69-year-old man came to our attention for rapid weight loss, postprandial epigastric pain and recurrent vomiting for at least 6 months. Doppler ultrasound showed both celiac artery and left renal vein stenosis with simultaneous left varicocele. Computed tomography showed a reduction of aortomesenteric space causing both left renal vein and duodenal stenosis, this latter confirmed by upper gastrointestinal fluoroscopic exam. The diagnosis of these three vascular compression syndromes (MALS, SMAS, and anterior NCS) has been formulated, based on clinical and imaging findings. We assumed that the postprandial crises caused by median arcuate ligament syndrome may induce a reduction of meals consumption and progressive weight loss which can be a cause of anterior nutcracker syndrome and superior mesenteric artery syndrome onset. Doppler ultrasound, in expert hands, allows to accurately diagnosing these syndromes which are often underestimated. Failure to recognize it and inadequate treatment could have serious consequences for patients' health.

Co-occurring superior mesenteric artery syndrome and nutcracker syndrome requiring Roux-en-Y duodenojejunostomy and left renal vein transposition: a case report and review of the literature

BACKGROUND

The duodenum and the left renal vein occupy the vascular angle made by the superior mesenteric artery and the aorta. When the angle becomes too acute, compression of either structure can occur. Each type of compression is associated with specific clinical symptoms that constitute a rare disorder. If clinical symptoms are mild, conservative treatment is implemented. However, surgery is often the only solution that can improve quality of life and/or avoid life-threatening complications. This report describes a case of a patient with both types of aortomesenteric compression that required two separate surgeries to alleviate all symptoms.

CASE PRESENTATION

A 20-year-old white woman presented to the Emergency Room complaining of sudden onset severe left flank and lower left quadrant abdominal pain, nausea, and vomiting. A clinical work-up revealed elevated white blood cells and hematuria. She was discharged with a diagnosis of urinary tract infection. Symptoms continued to worsen over the subsequent 2 months. Repeated and extensive clinical work-ups failed to suggest evidence of serious pathology. Ultimately, an endoscopy revealed obstruction of her duodenum, and barium swallow identified compression by the superior mesenteric artery, leading to the diagnosis of superior mesenteric artery syndrome. She underwent a Roux-en-Y duodenojejunostomy. Six weeks later she continued to have severe left-sided pain and intermittent hematuria. Venography revealed compression of the left renal vein, extensive pelvic varices, and significant engorgement of her left ovarian vein. A diagnosis of nutcracker syndrome was made and a left renal vein transposition was performed. Significant improvement was seen after 8 weeks.

CONCLUSIONS

The disorders associated with aortomesenteric compression can lead to serious symptoms and sometimes death. Diagnosis is challenging not only because of the lack of awareness of these rare disorders, but also because they are associated with symptoms that are similar to those seen in less serious diseases. Guidance for health care professionals with respect to relevant radiological and clinical markers needs to be reconsidered in order to clarify the etiology of the diseases and create better diagnostic protocols.

An unusual origin of the celiac trunk and the superior mesenteric artery in the thorax

The authors report a case of a 44-year-old male found to have unusual origins of the celiac trunk (CT) and superior mesernteric artrery (SMA) as revealed by routine multidetector computed tomograph (MDCT) angiography. The CT and SMA originate from the thoracic aorta (TA) 21 mm and 9 mm above the aortic hiatus, respectively. The median arcuate ligament (MAL) is located at the level of the L1-L2 intervertebral disc. The course of the CT descends in the thoracic cavity making a 14° acute downward angle in front of the TA; below the level of the MAL, the CT descends, making an angle of 47°. The course of the SMA descends at both the thoracic and abdominal level making an angle of 17°, and having an aortomesenteric distance of 9 mm at the level of the third part of the duodenum. In the present case, the supradiaphragmatic origin of the CT and the SMA was determined by their incomplete caudal descent, associated with a pronounced apparent descent of the diaphragm. A thoracic origin of the CT and SMA and the acute downward aortomesenteric angle (17°) associated with a reduced aortomesenteric distance at the level of the third part of the duodenum (9 mm), although no clinical signs are present, may predispose the patient to develop simultaneously a triple syndrome: the compression of CT by MAL (celiac axis compression syndrome), the compression of SMA by MAL (superior mesenteric artery compression syndrome), and the compression of the duodenum by the SMA (superior mesenteric artery syndrome).

Celiac artery compression syndrome: a radiological finding without clinical symptoms?

The aim of the paper is to determine the incidence of celiac artery compression (CAC) based on computed tomography (CT) scan and correlate the findings to the clinical presentation of patients presenting for CT scan in a hospital. Abdominal CT scans of patients were reviewed between September 2010 and November 2010. CAC was diagnosed if the celiac axis appeared to have a hook or U-shaped appearance with stenosis. The medical records of the patients were reviewed for gastrointestinal symptoms (abdominal pain, nausea, vomiting, constipation, diarrhea), as well as food fear and weight loss. Patients with CAC had lower incidence of symptoms compared with those without CAC (42.1 versus 65.3%, P = 0.042). A total of 450 patients were evaluated. In the end, 284 had both complete medical records and CT scans. The mean age for all patients was 51.3 ± 1.2 years. There were 124 men (42.6%) and 160 (57.4%) women. Nineteen (6.7%) patients had radiological evidence of CAC. CAC is not an uncommon CT finding in patients presenting for CT scan.

Celiac artery compression syndrome: an experience in a single institution in taiwan

Celiac artery compression syndrome (CACS) or median arcuate ligament (MAL) syndrome is a rare vascular disease. The clinical manifestations of CACS include the triad of postprandial pain, vomiting, and weight loss. The pathogenesis of CACS is the external compression of celiac artery by the MAL or celiac ganglion. Moreover, some authors also reported the compression with different etiologies, such as neoplasms of pancreatic head, adjacent duodenal carcinoma, vascular aneurysms, aortic dissection, or sarcoidosis. In the literature, most cases of CACS were reported from Western countries. In contrast, this disease was seldom reported in Oriental countries or regions, including Taiwan. Superior mesenteric artery syndrome (SMAS) is also a rare disease characterized by compression of the third portion of the duodenum by the SMA. The clinical features of SMAS are postprandial pain, vomiting, and weight loss. To date, there are no guidelines to ensure the proper treatment of patients with CACS because of its low incidence. Thus, tailored therapy for patients with CACS remains a challenge as well as the prediction of clinical response and prognosis. The aim of our present study was to investigate the clinical features, the association with SMAS, treatments, and outcomes of patients with CACS in a single institution in Taiwan.

Superior mesenteric artery syndrome in a 16-year-old with bilious emesis

Superior mesenteric artery (SMA) syndrome describes vascular compression of the third portion of the duodenum and presents with nausea, postprandial vomiting, and epigastric abdominal pain. The syndrome is rare and may be missed if appropriate radiologic studies are not performed or the clinical presentation is atypical. The clinical contexts in which SMA syndrome develops usually involve rapid weight loss, alterations in spine anatomy, or external increases in abdominal pressure. Diagnostic methods for identifying duodenal obstruction by the SMA include upper gastrointestinal barium contrast studies, computed tomography scans, or angiography of the aorta with either contrast or magnetic resonance angiography. Medical therapy relies upon nutritional rehabilitation with either jejunal tube feedings or parenteral nutrition until weight gain results in relief of the obstruction. In instances where this approach fails, surgical correction is necessary, most often with laparoscopic duodenojejunostomy.

Laparoscopic management of celiac artery compression syndrome

BACKGROUND

Celiac artery compression syndrome (CACS) remains a controversial diagnosis, despite several reported series documenting therapeutic efficacy of CA decompression. Traditional therapy consists of open surgical decompression, but since 2000, five isolated case reports have been published in which CACS has been successfully treated with laparoscopic techniques. This approach was adopted as the sole initial therapy for CACS at the Johns Hopkins Hospital in 2002. This article reports the results of a unique surgical series that triples the reported worldwide experience with this therapy.

METHODS

Fifteen patients (median age, 40.6 years) diagnosed with CACS underwent laparoscopic decompression by a single vascular surgeon. CACS was diagnosed by digital subtraction angiography in 14 patients and computed tomography (CT) angiography in one patient, with images acquired in both expiratory and inspiratory phases of respiration. CA decompression was offered after the results of a thorough workup for other pathology were negative, including upper and lower endoscopy, CT scanning, gastric and gallbladder emptying studies, upper gastrointestinal series, and small-bowel follow-through studies. Indications in all patients were abdominal pain and weight loss (average, 9 lbs). The procedure consisted of laparoscopic division of the median arcuate ligament and complete lysis of the CA from its origin on the aorta to its trifurcation.

RESULTS

Between November 2002 and September 2007, 15 consecutive patients underwent laparoscopic CA decompression. Median length of follow-up was 44.2 months. There were no operative deaths. Four patients were converted intraoperatively to an open decompression, all for intraoperative bleeding; only one required a blood transfusion. Average operating time was 189 minutes, and the average length of stay was 3.5 days. CA intervention was required in six patients, including three intraoperative procedures (1 patch angioplasty, 1 celiac bypass, 1 percutaneous angioplasty) and six late procedures (2 percutaneous angioplasties, 3 percutaneous stents, 1 celiac bypass). One complication occurred, a severe case of pancreatitis that developed 1 week after discharge. On follow-up, 14 of 15 patients subjectively reported significant improvement, and one patient remains symptomatic with no diagnosis.

CONCLUSION

Laparoscopic decompression of the CA may be a useful therapy for CACS, but there is potential for vascular injury, and adjunctive CA intervention is often required. Surgeons should consider laparoscopic CA decompression as a therapeutic alternative for CACS and should participate in the care of patients with this diagnosis.

[Wilkie's syndrome]

Loss of retroperitoneal fatty tissue as a result of a variety of debilitating conditions and noxa is believed to be the etiologic factor of superior mesenteric artery syndrome. A case of a 35 years old female patient with severe malnutrition and weight loss is presented, who developed superior mesenteric artery syndrome. Various theories of etiology, clinical course and treatment options of this uncommon disease are discussed. In our case, conservative management was inefficient, while surgical treatment aiming to bypass the obstruction by an anastomosis between the jejunum and the proximal duodenum (duodenojejunostomy) was successful. An interdisciplinary teamwork provides the most beneficial diagnostic and therapeutic result in this often underestimated disease.

Superior mesenteric artery syndrome caused by celiac axis compression syndrome: a case report and review of the literature

Celiac axis compression syndrome (CACS) is a rare entity of mesenteric ischemia, secondary to inadequate blood supply to the intestine, resulting in weight loss because of postprandial abdominal pain. Superior mesenteric artery (SMA) syndrome is an uncommon cause of intestinal obstruction manifesting with epigastric pain, bilious vomiting, and postprandial discomfort. Although the coexistence of both syndromes is very rare and has been reported only in eight patients in the literature, the CACS as a rare etiology of SMA syndrome has not yet been reported. Herein, we describe an uncommon case of SMA syndrome secondary to the CACS. The 27-year-old woman presented with epigastric pain, postprandial vomiting, and rapid body weight loss. The diagnosis of SMA syndrome was made by hypotonic duodenography and multidetector computer tomographic angiography. The CACS was also suspected by multidetector computer tomographic angiography. Surgical intervention was performed and the presence of CACS was confirmed. Her symptoms subsided shortly after operation and she was in good health at 1-year follow-up.