[Acute gastric dilatation with superior mesenteric artery syndrome in a young girl with anorexia nervosa]

The intersect of gastrointestinal symptoms and malnutrition associated with anorexia nervosa and avoidant/restrictive food intake disorder: Functional or pathophysiologic?-A systematic review

OBJECTIVE

Although multiple pathophysiologic changes develop within the gastrointestinal (GI) system in the setting of malnutrition, the etiology of the reported multitude of symptoms in those with anorexia nervosa and avoidant restrictive intake disorder, as well as their contribution toward disordered eating, remain poorly understood. This systematic review seeks to better understand how these physiologic changes of malnutrition of the esophagus, stomach, intestines, and pancreas contribute toward the reported GI symptoms, as well as better understand how celiac disease, inflammatory bowel disease, pelvic floor dysfunction, and Ehlers-Danlos syndrome contribute toward disordered eating.

METHODS

Studies of any design exploring the pathogenesis of complications and treatment strategies were included. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used to structure and complete the review.

RESULTS

A total of 146 articles were used for the review. The majority of studies were observational or case reports/case series.

DISCUSSION

Pathophysiologic changes of the esophagus, stomach, and intestines develop with malnutrition, although these changes do not consistently correlate with expressed GI symptoms in patients with restrictive eating disorders. Celiac disease and inflammatory bowel disease also contribute to disordered eating through the associated somatic GI complaints, while pelvic floor dysfunction and Ehlers-Danlos syndrome contribute through both somatic symptoms and functional symptoms. Indeed, functional GI symptoms remain problematic during the course of treatment, and further research is required to better understand the extent to which these symptoms are functional in nature and remit or remain as treatment ensues.

Wilkie's syndrome admitted for acute abdomen: A case presentation

Superior mesenteric artery syndrome, also known as Wilkie's Syndrome, is a life threatening clinical entity which developes as a result of obstructed second or third part of duodenum compressed between aorta and superior mesenteric artery. In this rare syndrome, a rapid weight loss is accompanied by stomach ache, abdominal distension, lack of appetite, nausea and vomiting after meals. In patients admitted for acute abdomen, superior mesenteric artery syndrome should be included in the differential diagnosis in case of a preceeding rapid weight loss. X-ray of barium passage, abdominal ultrasound, gastroscopy, abdominal angio-tomography or abdominal magnetic resonance angiography may be useful for diagnosis. Conservative and surgical approaches are available for the treatment. In this report we aimed to emphasize that superior mesenteric artery syndrome cases may admit for acute abdomen and that superior mesenteric artery syndrome should be included in differential diagnosis.

Increase body weight to treat superior mesenteric artery syndrome

INTRODUCTION

Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction resulting from vascular compression of the third part of the duodenum in the angle between the abdominal aorta and SMA.

CASE PRESENTATION

A 19-year-old woman with anorexia nervosa with upper gastrointestinal obstruction symptoms resorted to the emergency department. A diagnosis of SMA syndrome was made. Symptoms were solved with conservative treatment aimed at increase body weight.

DISCUSSION

SMA syndrome is most commonly associated with debilitating illnesses. Patients present with acute or insidious upper gastrointestinal obstruction symptoms. Aortomesenteric artery angle of ≤25° is the most sensitive measure of diagnosis. Advances in both enteral and parenteral nutrition led to a shift towards conservative treatment.

CONCLUSIONS

Low threshold of suspicion is important to make a timely diagnosis and treatment. A conservative treatment aimed at increasing body weight is the first-line approach, leaving surgical intervention for failure cases.

Gastrointestinal complications associated with anorexia nervosa: A systematic review

OBJECTIVE

A systematic review identifying gastrointestinal (GI) complications attributable to anorexia nervosa (AN) was completed.

METHOD

Studies of any design exploring the pathogenesis of complications and treatment strategies were included. The review was completed in accordance with PRISMA standards.

RESULTS

A total of 123 articles were retained, including one randomized control trial. The majority of included studies were case reports and case series. Controlled studies demonstrated that patients with AN were more likely to have delays in gastric motility, gastric emptying and intestinal transit than comparator groups although results were not uniform across all studies. Published reports suggest that complications can occur at any segment of the GI tract. These issues may derive as a consequence of severe malnourishment, from eating disorder related symptoms such as self-induced purging or from the refeeding process itself. Multiple studies noted that patients with AN report high rates of GI symptoms although in the few cases where medical testing was undertaken, correlations between self-reported symptoms and measurable pathology were not demonstrated.

DISCUSSION

GI complications may occur throughout the entire GI tract in patients with AN. It is recommended that clinicians use careful judgment when pursuing targeted investigation or introducing symptom specific treatments in response to GI complaints. Evidence suggests that most GI complications resolve with refeeding and cessation of ED symptoms.

Sudden death in eating disorders

Eating disorders are usually associated with an increased risk of premature death with a wide range of rates and causes of mortality. “Sudden death” has been defined as the abrupt and unexpected occurrence of fatality for which no satisfactory explanation of the cause can be ascertained. In many cases of sudden death, autopsies do not clarify the main cause. Cardiovascular complications are usually involved in these deaths. The purpose of this review was to report an update of the existing literature data on the main findings with respect to sudden death in eating disorders by means of a search conducted in PubMed. The most relevant conclusion of this review seems to be that the main causes of sudden death in eating disorders are those related to cardiovascular complications. The predictive value of the increased QT interval dispersion as a marker of sudden acute ventricular arrhythmia and death has been demonstrated. Eating disorder patients with severe cardiovascular symptoms should be hospitalized. In general, with respect to sudden death in eating disorders, some findings (eg, long-term eating disorders, chronic hypokalemia, chronically low plasma albumin, and QT intervals >600 milliseconds) must be taken into account, and it must be highlighted that during refeeding, the adverse effects of hypophosphatemia include cardiac failure. Monitoring vital signs and performing electrocardiograms and serial measurements of plasma potassium are relevant during the treatment of eating disorder patients.

Incidence and Risk Factors Associated with Superior Mesenteric Artery Syndrome following Surgical Correction of Scoliosis

Study Design

Retrospective study.

Purpose

To more accurately determine the incidence and clarify risk factors.

Overview of Literature

Superior mesenteric artery syndrome is one of the possible complications following correctional operation for scoliosis. However, when preliminary symptoms are vague, the diagnosis of superior mesenteric artery syndrome may be easily missed.

Methods

We conducted a retrospective study using clinical data from 118 patients (43 men and 75 women) who underwent correctional operations for scoliosis between September 2001 and August 2007. The mean patient age was 15.9 years (range 9~24 years). The risk factors under scrutiny were the patient body mass index (BMI), change in Cobb's angle, and trunk length.

Results

The incidence of subjects confirmed to have obstruction was 2.5%. However, the rate increased to 7.6% with the inclusion of the 6 subjects who only showed clinical symptoms of obstruction without confirmative study. The BMI for the asymptomatic and symptomatic groups were 18.4±3.4 and 14.6±3, respectively. The change in Cobb's angle for the asymptomatic and symptomatic groups were 24.8±13.6° and 23.4±9.1°, respectively. The change in trunk length for the asymptomatic and symptomatic groups were 2.3±2.1 cm and 4.5±4.8 cm, respectively. Differences in Cobb's angle and the change in trunk length between the two groups did not reach statistical significance, although there was a greater increase in trunk length for the symptomatic group than for the asymptomatic group.

Conclusions

Our study shows that the incidence of superior mesenteric artery syndrome may be greater than the previously accepted rate of 4.7%. Therefore, in the face of any early signs or symptoms of superior mesenteric artery syndrome, prompt recognition and treatment are necessary.

Fatal outcome from extreme acute gastric dilation after an eating binge

OBJECTIVE

A 22-year-old woman is presented with acute gastric dilation after an eating binge, who died of complications of acute reperfusion syndrome.

METHOD

A young patient was admitted in our clinic with critical condition without any significant previous medical history. Her initial complaints--diarrhea, vomiting and abdominal pain--began after an enormous food intake. There was no history of medications or toxic substances. Physical examination showed a normally-developed, well-nourished female in severe distress with an extremely distended abdomen. Femoral pulses were absent. The US and CT scan showed a dilated stomach, extended into the pelvis, dislocating the intestinal organs and compressed the aorta and mesenteric veins.

RESULTS

Urgent laparotomy was performed. An enormously distended stomach was encountered without volvulus, obstruction or adhesions. About 11 liters of gastric content was removed gastrotomy and nasogastric tube. Following the gastric decompression, the mesenteric and femoral pulses reappeared. During the operation, the cardio-respiratory status was stabilized, but in the following 24 hours irreversible shock developed, possibly due to the reperfusion of the retroperitoneal organs and the lower extremities. In the postoperative period disseminated intravascular coagulopathy developed. In an uncontrollable state of diffuse bleeding, 36 hours post-operation, the patient died. In retrospective investigation, the family confessed that previous psychological treatments which aimed at her bulimic attacks.

CONCLUSION

Acute gastric dilatation is very uncommon and is of various etiologies, two of these being anorexia nervosa and bulimia. Several cases documenting complications of gastric dilatation were published; however, such severe complications, involving gastric infarction and compression of the aorta with ischemic injury of the bowels and lower extremities, are rare.

[Superior mesenteric artery syndrome: a case report]

Superior mesenteric artery syndrom is a condition triggered by the compression of the third portion of the duodenum between the superior mesenteric artery and the aorta.

OBSERVATIONS

A twenty-one year old woman with a significant past history of neurological disease was referred for bilious vomiting and epigastric pain. The diagnosis of superior mesenteric artery syndrom was established by abdominal CT-scan. A laterolateral duodenojejunostomy was performed by laparotomy. After six months follow-up, this patient was asymptomatic.

CONCLUSION

Superior mesenteric artery syndrom can be easily diagnosed by abdominal CT-scan. Diagnosis and management of this infrequent syndrom are reviewed.

[Superior mesenteric artery syndrome: a cause of vomiting in children. Report of 3 cases]

Duodenal obstruction by Superior Mesenteric Artery (SMA) is a misdiagnosed vomiting syndrome in children. Several factors are involved, including rapid weight loss, rapid statural growth without weight augmentation. Diagnosis is suspected when an improvement is achieved by ventral decubitus and it is confirmed by plain films of the abdomen, GI study with barium and echography, measuring the aortomesenteric angle (inferior to 25-30 degrees ). Patients must at first be treated conservatively. Surgery is indicated for occlusive episodes with unsuccessful conservative therapy. The authors report 3 cases with different clinical presentation. However, all the patients presented important weight loss and vomiting.

Gastric dilatation in a girl with former obesity and atypical anorexia nervosa

OBJECTIVE

This case report describes a 16 year-old girl of normal weight with acute gastric dilatation due to binge eating habits.

METHOD AND RESULTS

Psychiatric assessment revealed a history of obesity and later atypical anorexia nervosa, but no current diagnosis of a typical eating disorder. After one month of daily binges a food excess was followed by an acute massive gastric dilatation which led to a laparotomy.

DISCUSSION

Clinicians should be aware that abnormal eating habits may cause severe somatic complications even in patients of normal weight who are not currently diagnosed as having a typical eating disorder. Careful investigation of eating habits might have resulted in therapeutic gastric emptying at an earlier stage, thus avoiding the need for surgery in our patient.

[Superior mesenteric artery syndrome]

The superior mesenteric artery syndrome (SMAS) is a rare complication of spine surgery. A series of four patients who experienced a SMAS after surgery for either post-traumatic quadriplegia, paraplegia or scoliosis is reported. SMAS is a condition in which the third portion of the duodenum is squeezed between the superior mesenteric artery anteriorly, and the aorta and vertebral column posteriorly. Weight loss is the major factor of development of a SMAS. Other causes include either spine surgery or trauma or application of a body cast. Delay in diagnosis may result in death. Diagnosis is obtained with either a CT scan with injection and oral contrast medium or an upper gastro-intestinal X-ray study. The latter allows the insertion of a feeding tube beyond the obstruction. A conservative treatment is started for correction of dehydration and electrolyte imbalance, and followed by nasojejunal feeding. Surgery is indicated in case of failure of conservative treatment.