She had earlier undergone treatment at a private hospital where barium examination had been performed. This revealed a markedly dilated stomach and duodenum, with an abrupt cut off at the level of the third part of the duodenum (Fig.1). Computerized tomogram (CT) scan also revealed similar findings. A diagnosis of superior mesenteric artery syndrome was made.

Fig. 1 Barium meal showing a markedly dilated "C" Loop of the duodenum. There is an abrupt, vertrical cut-off in the third part of the duodenum.

The child was taken up for emergency surgery after adequate preparation. The stomach and duodenum were grossly dilated, and the distal duodenum and small bowel were collapsed. The dilated duodenum was mobilized at the root of the transverse mesocolon, to the left of the superior mesenteric artery, and a side to side duodeno-jejunostomy was performed ten centimeters distal to the duodeno-jejunal flexure. The child had an uneventful recovery, and is presently well on a follow-up of one year.

The superior mesenteric artery syndrome (SMA syndrome) is a rare form of intestinal obstruction where the third part of the duodenum is compressed between the superior mesenteric artery anteriorly and the spine posteriorly. It is characterized by features of acute or chronic upper gastro-intestinal tract obstruction, and, although the exact aetiology is not known, the syndrome has been associated with sudden weight loss, spinal surgery, cast application, and, rarely, abdominal aortic aneurysm and pan-creatitis(1-3). It usually affects young females (10 to 39 years). The symptomatology is commonly chronic, with epigastric pain, bloating after meals, and vomitings. An acute presentation is uncommon.

Barium meal examination may show constant dilatation of the proximal duodenum with a delay in the passage of contrast distally. The presence of a vertical linear extrinsic pressure defect in the third part of the duodenum is characteristic(2,4) that dis-appears when the patient is placed in a prone position. These findings may be absent in the chronic form, hence, their absence does not exclude the disease. If negative, the exami-nation should be repeated, preferably during an acute attack(4). CT scan demonstrates compression of the duodenum.

Treatment can be conservative or surgical. Conservative treatment entails decompression of the stomach, intravenous fluids and management of electrolytes. Later, the patient can be advised to lie prone after meals to facilitate emptying of the stomach and duodenum and also, prescribed pro-kinetic agents. If the patient fails to respond to conservative treatment, or if symptoms are recurrent, surgery may be offered(4). A duodenojejunostomy with adequate size of the stoma (>5 cm) provides good results, is technically easier to perform than duodenal derotation, and, can also be performed laparoscopically(4). Recurrence after surgery is uncommon(3).

Robin Kaushik,
Ashok K. Attri,
From the Department of Surgery,
Govt. Medical College and Hospital,
Sector-32, Chandigarh, India.
E-mail: [email protected]