Superior mesenteric artery syndrome and the 'nutcracker phenomenon'

Interventional Management of a Rare Combination of Nutcracker and Wilkie Syndromes

Nutcracker and Wilkie syndromes are rare mesoaortic compression entities, and their association is even less common. Data on interventional treatment of these pathologies are still scarce, but results from limited case series are encouraging. We report the case of a previously healthy 45-year-old woman diagnosed with nutcracker and Wilkie syndromes who presented with macroscopic hematuria, intermittent pain in the left flank and hypogastric region, postprandial nausea, and unexplained significant weight loss. A successful endovascular approach with stent implantation in the left renal vein was performed, but the stent migrated toward the left kidney, and this acute complication was managed through an interventional strategy as well. At the three-month follow-up, the patient described a marked improvement in all symptoms, except for the macroscopic hematuria. As it was our strong belief that the approach was efficient, we further investigated the “hematuria”, which eventually led to the diagnosis of endometrial carcinoma. A hysterectomy and bilateral adnexectomy were planned, and chemoradiotherapy was initiated with the goal of preoperative tumor reduction. To our knowledge, this is the first reported case in which both Wilkie and nutcracker syndromes were effectively treated by stent implantation in the left renal vein, complicated with very early stent migration due to inadequate apposition to the less compliant venous lumen. The treatment of the duodenal compression was indirectly included in the stenting of the left renal vein, as reclaiming the venous lumen widened the aortomesenteric angle. The aim of this review is to discuss our center’s transcatheter experience with these rare disorders and explore the literature in order to establish the benefits and limitations of such an approach.

Laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy for superior mesenteric artery syndrome with dysphagia: a case report

Background

Superior mesenteric artery (SMA) syndrome denotes a mechanical duodenal obstruction between the SMA and aorta. Total parenteral or enteral nutrition is the treatment of choice. However, surgical intervention is indicated if the patient’s condition does not improve with conservative treatment. Here, we describe a case of SMA syndrome with dysphagia treated by laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy.

Case presentation

A 64-year-old man was admitted to another hospital because of appetite loss and vomiting. There, he was diagnosed as having superior mesenteric artery (SMA) syndrome after appropriate investigation. He had had a cerebral infarction at age 57 years, since which he had lived in social housing because of complications of that infarction. A nasogastric tube was inserted into the third portion of the duodenum beyond the constricted section. He was discharged 2 months after admission his condition having improved. He was subsequently referred to our hospital for gastrostomy because the nasogastric tube had been in place for a long time and his condition had not improved. Additionally, gastrostomy was needed as a route for enteral nutrition because he had dysphagia, which had persisted despite attempts at rehabilitation, restricting his food intake to small amounts. Computed tomography (CT) revealed compression of the third portion of the duodenum between the SMA and aorta. After obtaining informed consent, we planned an operative procedure. We performed laparoscopic gastrojejunostomy under general anesthesia, followed by laparoscopic-assisted percutaneous endoscopic gastrostomy. The operation time was 156 min and there was little blood loss. Contrast radiography on postoperative day 3 revealed no evidence of leakage or stenosis. Enteral nutrition via the gastrostomy was started. He was discharged from our hospital on the 27th postoperative day. The gastrostomy was well tolerated and there has been no evidence of recurrence of SMA syndrome during follow-up.

Conclusion

Gastrostomy is often performed to provide a route for administering enteral nutrition in patients with dysphagia. Development of SMA syndrome in patients with dysphagia necessitates operative management of the obstruction. Here, we describe a case of SMA syndrome with dysphagia treated by laparoscopic gastrojejunostomy with laparoscopic-assisted percutaneous endoscopic gastrostomy.

Coexistence of superior mesenteric artery syndrome and nutcracker phenomenon

Superior mesenteric artery (SMA) syndrome is a rare cause of upper gastrointestinal obstruction. Nutcracker syndrome occurs as the result of external compression of the left renal vein. Although they share a similar pathophysiology, SMA and nutcracker syndrome occurring simultaneously is rare. In this case report, we discuss the pathophysiology and unique computed tomography findings in a 25-year-old female patient diagnosed with SMA syndrome who was also incidentally found to have a coexisting nutcracker phenomenon. Due to similar pathogenesis, radiologists should consider the possibility of coexistence of these rare syndromes in appropriate patients.

Combined Superior Mesenteric Artery Syndrome and Nutcracker Syndrome in a Young Patient: A Case Report and Review of the Literature

Patient: Male, 18-year-old

Final Diagnosis: Superior mesenteric artery syndrome

Symptoms: Abdominal pain

Medication:—

Clinical Procedure: —

Specialty: Surgery

Effect of visceral fat tissue on superior mesenteric artery configuration: Is it superior to BMI?

BACKGROUND/AIMS

To determine the effect of visceral fat volume measured via computed tomography (CT) images of umbilical slices on superior mesenteric artery (SMA) configuration, as compared with body mass index (BMI). In addition, this study aims to determine the effect of lumbar lordosis angle (LLA) on SMA configuration.

MATERIALS AND METHODS

The study included 310 patients who underwent abdominal CT. On CT images, the aortomesenteric angle (AMA), the distance between SMA and aorta at three levels, and LLA were measured. Visceral fat volume was measured using three consecutive images obtained at the level of the umbilicus. The relationship among AMA, and distances measured between SMA and aorta, and visceral fat tissue volume were determined. The effect of LLA on AMA and distances measured between SMA and aorta was analyzed.

RESULTS

There was a significant positive correlation between visceral fat volume, and patient age, AMA, distances between SMA and aorta, LLA, and BMI (p<0.001). There were not any significant differences in AMA, distances between SMA and aorta, BMI, or visceral fat volume between the patients with an LLA of 20°-45° and those with an LLA >45° (p>0.05). There was a significant positive correlation between BMI, and AMA, distances between SMA and aorta (p<0.001). There was a significant positive correlation between visceral fat volume, and AMA, distances between SMA and aorta (p<0.001).

CONCLUSION

Visceral fat tissue volume is more valuable than BMI for evaluating the SMA configuration.

An update on gastrointestinal disturbances in eating disorders

Eating disorders, namely anorexia nervosa, bulimia nervosa and binge eating disorder are frequent diseases and often complicated by comorbidities, e.g. psychiatric or cardiovascular comorbidities. It is to note that also gastrointestinal symptoms/complications are frequently observed in patients with eating disorders. These diseases will be presented in the current review along with - where known - possible underlying mechanisms. Lastly, gaps in knowledge will be highlighted.

Superior Mesenteric Artery Syndrome: Clinical, Endoscopic, and Radiological Findings

Background

The superior mesenteric artery (SMA) syndrome is a rare entity presenting with upper gastrointestinal tract obstruction and weight loss. Studies to determine the optimal methods of diagnosis and treatment are required.

Aims and Methods

This study aims at analyzing the clinical presentation, diagnosis, and management of SMA syndrome. Ten cases of SMA syndrome out of 2074 esophagogastroduodenoscopies were suspected. A contrast-enhanced computed tomography (CECT) scan was performed to confirm the diagnosis. After, a gastroenterologist and a nutritionist personalized the therapy. Furthermore, we compared the demographical, clinical, endoscopic, and radiological parameters of these cases with a control group consisting of 10 cases out of 2380 EGDS of initially suspected (but not radiologically confirmed) SMA over a follow-up 2-year period (2015-2016).

Results

The prevalence of SMA syndrome was 0.005%. Median age and body mass index were 23.5 years and 21.5 kg/m², respectively. Symptoms developed between 6 and 24 months. Median aortomesenteric angle and aorta-SMA distance were 22 and 6 mm, respectively. All patients improved on conservative treatment. In our series, a marked (>5 kg) weight loss (p = 0.006) and a long-standing presentation (more than six months in 80% of patients) (p = 0.002) are significantly related to a diagnosis of confirmed SMA syndrome at CECT after an endoscopic suspicion. A “resembling postprandial distress syndrome dyspepsia” presentation may be helpful to the endoscopist in suspecting a latent SMA syndrome (p = 0.02). The narrowing of both the aortomesenteric angle (p = 0.001) and the aortomesenteric distance (p < 0.001) was significantly associated with the diagnosis of SMA after an endoscopic suspicion; however, the narrowing of the aortomesenteric distance seemed to be more accurate, rather than the narrowing of the aortomesenteric angle.

Conclusion

SMA syndrome represents a diagnostic and therapeutic challenge. Our results show the following findings: the importance of the endoscopic suspicion of SMA syndrome; the preponderance of a long-standing and chronic onset; a female preponderance; the importance of the nutritional counseling for the treatment; no need of surgical intervention; and better diagnostic accuracy of the narrowing of the aorta-SMA distance. Larger prospective studies are needed to clarify the best diagnosis and management of the SMA syndrome.

A Model Example: Coexisting Superior Mesenteric Artery Syndrome and the Nutcracker Phenomenon

Superior mesenteric artery (SMA) syndrome is a rare cause of gastrointestinal obstruction, caused by external compression of the third part of the duodenum by the SMA. It may be associated with the Nutcracker phenomenon: external compression of the left renal vein. To our knowledge, there are few reports in the literature describing the coexistence of these two conditions and so we take this opportunity to highlight a rare cause of the acute abdomen that might otherwise be overlooked in cases of nonspecific abdominal findings and potentially unremarkable initial investigations. We report a case of SMA syndrome and Nutcracker phenomenon in a 19-year-old female who presented to our emergency department with a short history of epigastric pain and emesis. The SMA syndrome is thought to develop as the result of an abnormally narrow angle between the proximal SMA and the aorta, for which a number of predisposing factors have been described. Surgical options exist; however, the SMA syndrome is typically managed conservatively in the first instance, consistent with the approach described in this case. The Nutcracker phenomenon may give rise to the Nutcracker syndrome in the presence of typical clinical manifestations; however, these did not feature in this case.

Superior mesenteric artery syndrome accompanying with nutcracker syndrome: a case report

Introduction:

Superior mesenteric artery syndrome is an uncommon cause of duodenal obstruction, and its manifestations are generally associated with compression on the third part of the duodenum between the abdominal aorta and superior mesenteric artery.

Case Presentation:

In this report, a patient is described presenting with epigastric pain and weight loss due to superior mesenteric artery syndrome. The patient has also nutcracker syndrome, which is the compression of the left renal vein between the aorta and the superior mesenteric artery at its origin.

Conclusions:

In addition to an appropriate clinical history, CT findings indicating decreased aortomesenteric angle and a shortened aortomesenteric distance can suggest the diagnosis for both the superior mesenteric artery syndrome and accompanying nutcracker syndrome.

SMA Syndrome Treated by Single Incision Laparoscopic Duodenojejunostomy

Superior mesenteric artery (SMA) syndrome is a mechanical duodenal obstruction by the SMA. The traditional approach to SMA syndrome was open bypass surgery. Nowadays, a conventional approach has been replaced by laparoscopic surgery. But single incision laparoscopic approach for SMA syndrome is rare. Herein, we report the first case of SMA syndrome patient who was treated by single incision laparoscopic duodenojejunostomy.

Measurement of the Distance and Angle Between the Aorta and Superior Mesenteric Artery on CT Scan: Values in Indian Population in Different BMI Categories

The primary intention of the study was to "prove" that the reduced angle and distance between the superior mesenteric artery (SMA) and aorta significantly correlates with reduced body mass index (BMI). This in turn indicates the strong etiological role of this factor for causation of SMA syndrome. (Most literature till date still mentions sudden depletion of fat pad between the vessels as a "proposed predisposing factor"). The superior mesenteric artery syndrome is characterized by the compression of the third segment of the duodenum by the mesentery at superior mesenteric artery level and a resulting duodenal (±gastric) dilatation. The disease is closely related with the depletion of the fat pad between the vessels narrowing the angle and reducing the distance between the vessels. A prospective study of 100 patients (58 males and 42 females) in the age range 15-85 years (mean age 50 years) who had undergone CT scan for various other complaints. CT scan had been performed with routine protocol comprising plain phase followed by arterial and venous phase by measuring the angle between the aorta and superior mesenteric artery, and also BMI was calculated. Mean values for distance and angle were obtained with standard deviation and 95 % confidence intervals. Pearson coefficients were also calculated and results tabulated. A strong positive correlation exists between BMI and the angle between the aorta and SMA. With increment in BMI, the angle also increases so less chance of developing superior mesenteric artery syndrome.