Superior Mesenteric Artery Syndrome with Para Duodenal Hernia: A Rare and Underdiagnosed Cause of Intestinal Obstruction

Abstract

Introduction: Superior Mesenteric Artery (SMA) syndrome also known as chronic duodenal ileus, Wilkie syndrome, arterio-mesenteric duodenal compression syndrome and cast syndrome is a rare cause of proximal bowel obstruction with an incidence that range between 0.013 and 0.3%. Case Report: Our patient aged 35 years female presented in emergency department with complaints of severe abdominal pain, excessive vomiting, inability to pass flatus and motion for 2 days. CT scan of abdomen with contrast showed that stomach and duodenum were grossly distended up to third part of duodenum which was compressed by SMA with reduced aorto-mesenteric angle of 18 degree and distance of 7.3 mm. Nasogastric tube was passed and parenteral nutrition was maintained. But patient did not respond to conservative management, hence decision for laparotomy was taken and Duodenojejunostomy was done. Discussion: SMA syndrome is a diagnostic and therapeutic challenge because of its rarity. Various surgical procedures have been considered for surgical management including gastrojejunostomy, Strong procedure (a division of the ligament of Treitz) and duodenojejunostomy. Most surgeons prefer duodenojejunostomy due to reported success rates of 80% to 100% with reduced postoperative pain, shortened hospital stay. Conclusion: SMA syndrome is an underdiagnosed condition. CT scan is a highly useful modality to diagnose SMA syndrome.