S6230 GLP-1-Induced Superior Mesenteric Artery Syndrome: An Interesting Complication in the Age of GLP-1 and SGLT-2 Medications

Introduction: With the advent of glucagon-like peptide-1 (GLP-1) and sodium-glucose cotransporter-2 (SGLT-2) medications for a variety of indications, including diabetes, obesity, obstructive sleep apnea, and metabolic associated steatohepatitis, there has been a large boom in the usage of these medications in recent years. While rarely reported in the literature, GLP-1 induced superior mesenteric artery (SMA) syndrome may become more prevalent with increased prescription of these medications. Case Description/Methods: The patient is a 77-year-old woman, with a history of type 2 diabetes, who presented due to post-prandial epigastric pain, nausea, and vomiting. The patient reported significant weight loss over the last few months after starting dulaglutide. Computed tomography of the abdomen showed significant distention of the stomach and proximal duodenum. Narrowing of the mid to distal duodenum was noted as it passed between the aorta and SMA with decreased aortomesenteric angle. Superior mesenteric angle was noted to be approximately 13 degrees, compared to a normal SMA angle several months prior. Upper gastrointestinal (GI) series showed abdominal distention with enlargement of the duodenal bulb and delayed passage of contrast from the duodenal bulb into the remaining portions of the duodenum. SMA symptoms were successfully treated with conservative management, improving with intravenous fluids, NG tube placement, and anti-nausea management. Follow-up endoscopy after resolution of symptoms showed no evidence of strictures or other structural causes of obstruction. Discussion: SMA syndrome is associated with compression of the third portion of the duodenum due to narrowing of the space between the SMA and aorta. SMA syndrome is often related to loss of the mesenteric fat pad and patients usually present with symptoms consistent with proximal small bowel obstruction. While weight loss is a common cause of SMA syndrome, other causes include anatomic abnormalities, cancer, AIDS, and malabsorption syndromes. SMA syndrome can be treated conservatively with nasogastric tube decompression and electrolyte replacement. If conservative management is not effective, surgical intervention may be required. Monitoring patients on GLP-1 and SGLT-2 medications is recommended to prevent proximal small bowel obstructions and prevent complications including electrolyte abnormalities, gastric perforation, and gastric pneumatosis. Increased awareness of SMA syndrome as a potential complication of GLP-1 and SGLT-2 medications is essential, especially as prescription of these medications becomes more widely prevalent.