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  • • Obstruction of the third portion of the duodenum by compression between the superior mesenteric vessels and the aorta

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Epidemiology

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  • • Most commonly appears after rapid weight loss following injury or burns

    • Acute loss of mesenteric fat is thought to permit the artery to drop posteriorly, trapping the bowel like in a pair scissors

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Symptoms and Signs

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  • • Epigastric bloating

    • Crampy pain relieved by vomiting

    • Symptoms may remit in the prone position

    • Anorexia and postprandial pain lead to additional malnutrition and weight loss

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Imaging Findings

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  • Upper GI contrast radiography

    • -Demonstrates a widened duodenum proximal to a sharp obstruction where the artery crosses the third portion of the duodenum, as well as increased duodenal peristalsis proximal to the arterial blockage

      -When the patient moves to the knee-chest position, the passage of contrast material is suddenly unimpeded

    Angiography

    • -Shows an angle of 25 degrees or less between the superior mesenteric artery and the aorta

      -Not recommended for routine evaluation of obvious cases

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  • • Onset of epigastric bloating and crampy pain relieved by vomiting following rapid weight loss should be evaluated by upper GI contrast radiography

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Rule Out

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  • • Intestinal malrotation with duodenal obstruction by congenital bands

    • Involvement of the duodenum by scleroderma with diminished duodenal peristalsis

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  • • Signs and symptoms consistent with duodenal obstruction, particularly in the setting of rapid weight loss should prompt upper GI contrast radiography

    • Upper GI contrast radiography will confirm the diagnosis in most cases

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When to Admit

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  • • High-grade obstruction with vomiting and inability to tolerate enteral nutrition

    • Severe abdominal pain

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  • • Postural therapy may suffice

    • -The patient should be placed prone in the knee-chest position when symptomatic or in anticipation of postprandial difficulties

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Surgery

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Indications

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  • • Chronic obstruction: Division of suspensory ligament and mobilization of duodenum, or duodenojejunostomy

    • Malrotation: Mobilization of the

    • duodenojejunal flexure

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Prognosis

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  • • Surgical correction produces good long-term results

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References

Diwakaran HH et al. Superior mesenteric artery syndrome. Gastroenterology. 2001;121:516, 746.
Richardson WS, Surowiec WJ. Laparoscopic repair of superior mesenteric artery syndrome. Am J Surg. 2001;181:377.  [PubMed: 11438278]

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