S6326 Superior Mesenteric Artery Syndrome With Duodenal Ulcer: A Case Report

Introduction: Superior mesenteric artery syndrome (SMAS) was first described in 1861 and has transitioned its name from chronic duodenal ileus to superior mesenteric syndrome. SMAS is a life-threatening condition that presents nausea, vomiting, post-prandial abdominal pain, significant unintentional weight loss. SMAS is usually predisposed by conditions that trigger unintentional weight loss resulting in loss of mesenteric pad of fat leading to impingement of distal duodenum between superior mesenteric artery and aorta. Case Description/Methods: A 40-year-old man presented with a 6-month history of progressive postprandial abdominal pain and unintentional weight loss. Pain was associated with early satiety, loss of appetite, and markedly decreased oral intake. He did notice subjective significant unintentional weight loss. On examination, he appeared cachectic and had abdominal tenderness in the right and left upper quadrants. A contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis demonstrated gastric, small bowel, and colonic dilatation, with compression of the duodenum between the abdominal aorta and the superior mesenteric artery. An esophagogastroduodenoscopy (EGD) performed under fluoroscopic guidance revealed grade B reflux of esophagitis, a markedly dilated stomach, and a large, deep duodenal ulcer causing luminal deformity. A biopsy of the ulcer was obtained. Multiple attempts to place a Naso jejunal tube for gastric decompression and post-pyloric feeding were unsuccessful, likely due to duodenal narrowing from ulcer-related deformity or extrinsic compression from suspected SMA syndrome. Biopsy results later confirmed infection with Helicobacter pylori. Discussion: The third part of the duodenum is located between the superior mesenteric artery (SMA) root and aorta (anteriorly) while it is posteriorly related to the spine. In SMAS the angle between SMA and aorta reduces commonly due to loss of mesenteric pad of fat due to underlying debilitating conditions include malignancies, malabsorption syndromes, AIDS, trauma, burn, bariatric surgery, spinal cord injury, paraplegia, substance abuse. While SMAS itself causes unintentional weight loss, our patient’s weight loss was likely triggered by longstanding undiagnosed helicobacter pylori related duodenal ulcer. The management of this SMAS requires reversing or removing the precipitating factors (like H. pylori induced peptic ulcer disease) as well as correcting any secondary complications.