S6222 A Gut-Wrenching Detox: Superior Mesenteric Artery Syndrome as a Rare Sequela of Buprenorphine Withdrawal

Introduction: Superior mesenteric artery (SMA) syndrome is a rare gastrointestinal disorder characterized by duodenal compression between the aorta and SMA, often linked to significant weight loss. Rarely, it may occur during opioid withdrawal. Buprenorphine, a partial opioid agonist, can precipitate abrupt withdrawal, causing dehydration, fluid shifts, and retroperitoneal fat loss—factors that contribute to SMA syndrome. We present a unique case of SMA syndrome developing during buprenorphine-assisted detoxification in a patient with opioid use disorder. Case Description/Methods: Sixty-five-year-old man with daily heroin use was hospitalized for opioid withdrawal management. Buprenorphine was initiated on the next day. Within 24 hours, he developed persistent bilious vomiting, abdominal pain, and diarrhea, leading to severe dehydration and syncope. He had no history of eating disorders, weight loss, GI disease, or medications known to predispose to SMA syndrome. His body mass index was 24.2 (66 kg) prior to admission, decreasing slightly to 65 kg during hospitalization. Symptoms persisted for 9 days. On exam, he had a distended, tender epigastric region and dry mucosa. Labs showed leukocytosis, creatinine 3.10 mg/dL, and electrolyte disturbances. Non-contrast abdominal computed tomography revealed gastric and duodenal distention with a decreased aortomesenteric angle (16.7°), confirming SMA syndrome. He was managed with nasogastric decompression, bowel rest, intravenous fluids, and a gradual reintroduction of a low-fat, low-fiber diet, with resolution of symptoms. He was discharged with outpatient addiction support. Discussion: SMA syndrome is typically linked to rapid weight loss and fat depletion; however, this case suggests buprenorphine-precipitated opioid withdrawal as a novel trigger. The sudden receptor displacement during buprenorphine induction may result in severe GI symptoms, fluid shifts, and fat loss contributing to duodenal compression. This case is the first reported instance of SMA syndrome arising in the context of buprenorphine-assisted withdrawal.