Superior mesenteric artery syndrome
- Sherry Scovell, MD, FACS
Sherry Scovell, MD, FACS
- Assistant Professor in Surgery
- Massachusetts General Hospital
- Allen Hamdan, MD
Allen Hamdan, MD
- Clinical Director of Vascular and Endovascular Surgery
- Associate Professor
- Harvard Medical School
- Section Editors
- J Thomas Lamont, MD
J Thomas Lamont, MD
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — Anorectal Disorders and Misc. Lower GI Disease
- Section Editor — Nutrition, Malabsorption, and Misc. Upper GI Disease
- Professor of Medicine
- Harvard Medical School
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Sciences Center - Dallas Campus
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Superior mesenteric artery syndrome is an unusual cause of proximal intestinal obstruction. It has been referred to by a variety of other names including Cast syndrome, Wilkie syndrome, arteriomesenteric duodenal obstruction, and chronic duodenal ileus [1,2]. The syndrome is characterized by compression of the third portion of the duodenum due to narrowing of the space between the superior mesenteric artery and aorta and is primarily attributed to loss of the intervening mesenteric fat pad.
There remains some controversy surrounding a diagnosis of superior mesenteric artery syndrome since symptoms do not always correlate well with abnormal anatomic findings on radiologic studies, and symptoms may not resolve completely following treatment [3,4]. Furthermore, the diagnosis may be confused with other anatomic or motility-related causes of duodenal obstruction .
The diagnosis and treatment of superior mesenteric artery syndrome will be reviewed here. The management of bowel obstruction is discussed elsewhere. (See "Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults".)
The third portion of the duodenum passes between the aorta and the superior mesenteric artery (figure 1 and image 1). The duodenum typically crosses anterior to the aorta at the level of the third lumbar vertebral body suspended by its attachment to the ligament of Treitz.
The superior mesenteric artery arises from the anterior aspect of the aorta at the level of the L1 vertebral body. It is enveloped in fatty and lymphatic tissue and extends in a caudal direction at an acute angle into the mesentery. In the majority of patients, the normal angle between the superior mesenteric artery and the aorta is between 38 and 65º due, in part, to the mesenteric fat pad . This angle correlates with body mass index . The aorto-mesenteric distance is normally 10 to 28 mm .
- DORPH MH. The cast syndrome; review of the literature and report of a case. N Engl J Med 1950; 243:440.
- Wilkie, DP. Chronic duodenal ileus. Br J Surg 1921; 9:204.
- Cohen LB, Field SP, Sachar DB. The superior mesenteric artery syndrome. The disease that isn't, or is it? J Clin Gastroenterol 1985; 7:113.
- Ylinen P, Kinnunen J, Höckerstedt K. Superior mesenteric artery syndrome. A follow-up study of 16 operated patients. J Clin Gastroenterol 1989; 11:386.
- Hines JR, Gore RM, Ballantyne GH. Superior mesenteric artery syndrome. Diagnostic criteria and therapeutic approaches. Am J Surg 1984; 148:630.
- DERRICK JR, FADHLI HA. SURGICAL ANATOMY OF THE SUPERIOR MESENTERIC ARTERY. Am Surg 1965; 31:545.
- Ozkurt H, Cenker MM, Bas N, et al. Measurement of the distance and angle between the aorta and superior mesenteric artery: normal values in different BMI categories. Surg Radiol Anat 2007; 29:595.
- Sapkas G, O'Brien JP. Vascular compression of the duodenum (cast syndrome) associated with the treatment of spinal deformities. A report of six cases. Arch Orthop Trauma Surg 1981; 98:7.
- Merrett ND, Wilson RB, Cosman P, Biankin AV. Superior mesenteric artery syndrome: diagnosis and treatment strategies. J Gastrointest Surg 2009; 13:287.
- Agarwal T, Rockall TA, Wright AR, Gould SW. Superior mesenteric artery syndrome in a patient with HIV. J R Soc Med 2003; 96:350.
- Stümpfle R, Wright AR, Walsh J. Superior mesenteric artery syndrome in an HIV positive patient. Sex Transm Infect 2003; 79:262.
- Di Lecce F, Paini PB, Pagliari C, et al. [Superior mesenteric venous thrombosis. Report of 2 cases and review of the literature]. Chir Ital 2003; 55:77.
- Smith BM, Zyromski NJ, Purtill MA. Superior mesenteric artery syndrome: an underrecognized entity in the trauma population. J Trauma 2008; 64:827.
- Reckler JM, Bruck HM, Munster AM, et al. Superior mesenteric artery syndrome as a consequence of burn injury. J Trauma 1972; 12:979.
- Goitein D, Gagné DJ, Papasavas PK, et al. Superior mesenteric artery syndrome after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obes Surg 2004; 14:1008.
- Clapp B, Applebaum B. Superior mesenteric artery syndrome after Roux-en-y gastric bypass. JSLS 2010; 14:143.
- Baker MT, Lara MD, Kothari SN. Superior mesenteric artery syndrome after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006; 2:667.
- Schroeppel TJ, Chilcote WS, Lara MD, Kothari SN. Superior mesenteric artery syndrome after laparoscopic Roux-en-Y gastric bypass. Surgery 2005; 137:383.
- Laffont I, Bensmail D, Rech C, et al. Late superior mesenteric artery syndrome in paraplegia: case report and review. Spinal Cord 2002; 40:88.
- Barnes JB, Lee M. Superior mesenteric artery syndrome in an intravenous drug abuser after rapid weight loss. South Med J 1996; 89:331.
- Pentlow BD, Dent RG. Acute vascular compression of the duodenum in anorexia nervosa. Br J Surg 1981; 68:665.
- Gwee K, Teh A, Huang C. Acute superior mesenteric artery syndrome and pancreatitis in anorexia nervosa. Australas Psychiatry 2010; 18:523.
- Zerańska M, Tomaszewicz-Libudzic C, Jagielska G, Komender J. [Surgical complications occurring during hospitalization of patients with anorexia nervosa--literature review and a discussion of three cases]. Psychiatr Pol 2002; 36:579.
- Adson DE, Mitchell JE, Trenkner SW. The superior mesenteric artery syndrome and acute gastric dilatation in eating disorders: a report of two cases and a review of the literature. Int J Eat Disord 1997; 21:103.
- Zadegan F, Lenoir T, Drain O, et al. [Superior mesenteric artery syndrome following correction of spinal deformity: case report and review of the literature]. Rev Chir Orthop Reparatrice Appar Mot 2007; 93:181.
- Schwartz A. Scoliosis, superior mesenteric artery syndrome, and adolescents. Orthop Nurs 2007; 26:19.
- Vitale MG, Higgs GB, Liebling MS, et al. Superior mesenteric artery syndrome after segmental instrumentation: a biomechanical analysis. Am J Orthop (Belle Mead NJ) 1999; 28:461.
- Zhu ZZ, Qiu Y. Superior mesenteric artery syndrome following scoliosis surgery: its risk indicators and treatment strategy. World J Gastroenterol 2005; 11:3307.
- Crowther MA, Webb PJ, Eyre-Brook IA. Superior mesenteric artery syndrome following surgery for scoliosis. Spine (Phila Pa 1976) 2002; 27:E528.
- Cho KR, Jo WM. Superior mesenteric artery syndrome after esophagectomy with cervical esophagogastrostomy. Ann Thorac Surg 2006; 82:e37.
- Iwaoka Y, Yamada M, Takehira Y, et al. Superior mesenteric artery syndrome in identical twin brothers. Intern Med 2001; 40:713.
- Caspi B, Deutsch H, Grunshpan M, et al. Prenatal manifestation of superior mesenteric artery syndrome. Prenat Diagn 2003; 23:932.
- Tseng CK, Su WB, Lai HC, et al. Superior mesenteric artery syndrome caused by celiac axis compression syndrome: a case report and review of the literature. Eur J Gastroenterol Hepatol 2008; 20:578.
- Lim JE, Duke GL, Eachempati SR. Superior mesenteric artery syndrome presenting with acute massive gastric dilatation, gastric wall pneumatosis, and portal venous gas. Surgery 2003; 134:840.
- Fuhrman MA, Felig DM, Tanchel ME. Superior mesenteric artery syndrome with obstructing duodenal bezoar. Gastrointest Endosc 2003; 57:387.
- Anderson FH. Megaduodenum. A case report and literature review. Am J Gastroenterol 1974; 62:509.
- Neri S, Signorelli SS, Mondati E, et al. Ultrasound imaging in diagnosis of superior mesenteric artery syndrome. J Intern Med 2005; 257:346.
- Unal B, Aktaş A, Kemal G, et al. Superior mesenteric artery syndrome: CT and ultrasonography findings. Diagn Interv Radiol 2005; 11:90.
- Lippl F, Hannig C, Weiss W, et al. Superior mesenteric artery syndrome: diagnosis and treatment from the gastroenterologist's view. J Gastroenterol 2002; 37:640.
- Santer R, Young C, Rossi T, Riddlesberger MM. Computed tomography in superior mesenteric artery syndrome. Pediatr Radiol 1991; 21:154.
- Applegate GR, Cohen AJ. Dynamic CT in superior mesenteric artery syndrome. J Comput Assist Tomogr 1988; 12:976.
- Munns SW, Morrissy RT, Golladay ES, McKenzie CN. Hyperalimentation for superior mesenteric-artery (cast) syndrome following correction of spinal deformity. J Bone Joint Surg Am 1984; 66:1175.
- Biank V, Werlin S. Superior mesenteric artery syndrome in children: a 20-year experience. J Pediatr Gastroenterol Nutr 2006; 42:522.
- STRONG EK. Mechanics of arteriomesentric duodenal obstruction and direct surgical attack upon etiology. Ann Surg 1958; 148:725.
- Wilson-Storey D, MacKinlay GA. The superior mesenteric artery syndrome. J R Coll Surg Edinb 1986; 31:175.
- Gersin KS, Heniford BT. Laparoscopic duodenojejunostomy for treatment of superior mesenteric artery syndrome. JSLS 1998; 2:281.
- Richardson WS, Surowiec WJ. Laparoscopic repair of superior mesenteric artery syndrome. Am J Surg 2001; 181:377.
- Bermas H, Fenoglio ME. Laparoscopic management of superior mesenteric artery syndrome. JSLS 2003; 7:151.
- Massoud WZ. Laparoscopic management of superior mesenteric artery syndrome. Int Surg 1995; 80:322.
- PATIENTS AT RISK
- CLINICAL EVALUATION
- Differential diagnosis
- DIAGNOSTIC STUDIES
- Plain abdominal films
- Oral contrast studies
- Diagnostic imaging criteria
- CONSERVATIVE THERAPY
- Gastrointestinal decompression
- Correction of electrolyte abnormalities
- Nutritional support
- SURGICAL MANAGEMENT
- OPEN SURGERY
- Laparoscopic approach
- Follow up
- Outcomes and complications of surgery
- SUMMARY AND RECOMMENDATIONS