An 18-year-old male with no significant past medical history presents with diffuse abdominal pain and multiple episodes of non-bloody, non-bilious vomiting for three days. The patient was seen yesterday at another facility and states he was diagnosed with gastritis and discharged with Zofran, which provided no relief. He denies fever, diarrhea, or urinary symptoms and states his last bowel movement was two days ago and was consistent with his usual bowel movements.
Vitals: T 97.7ºF; HR 138; BP 122/98; RR 18; O2 sat 99% on RA General: Thin male, appears uncomfortable Abdominal: Mild distention with diffuse tenderness to palpation; no guarding or rebound tenderness
White blood cell (WBC) count: 13k Complete metabolic panel (CMP): Mild hypokalemia; otherwise unremarkable Lactate: 4.9 Urinalysis (UA): Mild ketonuria; no hematuria; no evidence of infection
Superior Mesenteric Artery (SMA) syndrome also known as Wilke’s or Cast Syndrome is a condition where the third section of the duodenum gets compressed between the superior mesenteric artery and the aorta leading to a proximal obstruction in the duodenum and stomach. The most common etiology of SMA syndrome is the loss of the mesenteric fat pad surrounding the SMA. This leads to an acute angulation between the SMA and the aorta, thus compressing the duodenum and causing a partial or complete obstruction. While the condition is rare, predisposing factors include sudden weight loss and chronic illnesses such as malabsorption syndromes, AIDS, and malignancy.
Treatment in the acute stage is conservative management including gastric decompression, IV fluids, correction of electrolyte abnormalities, and nutritional support, which may include temporary gastro-jejunostomy (GJ) tube placement. Severe refractory cases may require surgical intervention. This patient was admitted and treated conservatively, including a temporary GJ tube placement which was removed a few months later.
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