sma syndrome

7/31/2019 SMA Syndrome

1/27

SUPERIOR MESENTERIC ARTERYSYNDROME

Dr.P. Naga Raja

Pg,Dept of gen .surg, CAIMS


2/27

Mr. Lakshmi Narayana

40 yrs old

C/O Pain abdomen

Vomiting

Abd distension

HISTORY OF PRESENT ILLNESS ;pain upper abdomen, colicky,aggr by food

intake

vomitings-bilious, non projectile

distension started in the upper abd,now

extending upto below umbilicus

He suffered similar attacks of abd

distension, vomitings many times on & off since

12 yrs&was treated at various hospitals

lost wt of 10kgs in 2 months

occasional smoker

2days


3/27

thin built,cachectic,pale

signs of moderate dehydration

On abdominal examination

gross distension of abd

VGP

on introduction of naso gastric tube,1500ml of bilious fluid came out with

relief of distensionNO lump/Organo megaly /free fluid found.


4/27

X-ray abdomen erect

USGdistended stomach and duodenum up to 3rd part

BMFT

dilated stomach without any filling defects.The duodenum up to mid part of the 3rd segment is dilated in calibre with an

abrupt linear cut off of the barium column in mid 3rd part of duodenum (supine

position) with subtle to and fro motion in the proximal duodenum. Contrast

passed freely in left lateral decubitus position in to the distal part of the intestine.

Features S/O extrinsic compression of SMA over the mid part of D3.


5/27

dilated 2nd part of the duodenum retrocolic passage for mobilized jejunum

side to end duodeno-jejunal anastamosis


6/27

end to side jejuno-jejunal anastamosis

passage of the contrast in to the

jejunum from the duodenum


7/27

Superior mesenteric artery syndrome


8/27

TERMINOLOGY

Chronic duodenal ileus

Vascular compression of the duodenum

Gastromesenteric ileus

Arteriomesenteric duodenal compression syndrome

Wilkies disease

SMA syndrome

cast syndrome


9/27

ANATOMYSMA comes off the aorta at an acute angle

D3 passes through this angle,hitched up at its junction wth D4 by lig of treitz

Aortomesenteric angle

contents

measurement


10/27

Factors precipitating obstruction

Sudden wt loss

Rapid growth in height

Increased lordosis

Short mesentery

High attachment of lig. of treitz

Dilatation of arteries


11/27

Conditions associated

Severe wasting conditionsburns,

trauma,

eating disorders,

drug abuse

Prolonged bed rest----head injury

cerebral palsyparaplegia

Body cast

Adolescent growth spurt

Post operative -----adhesions

---major surgeryAbdominal aneurysm


12/27

Clinical featuresYoung adults

F-60%Always thin built

Chronic SMASEpigastric pain with fullness& bloating after meals

Vomiting may occur & provides reliefSymptoms relieved by posture

Symptoms are intermittent with periods of wks/mths between attacks

Chronic peptic ulcers

Abd exam


13/27

Acute SMAS

Less common

Precipitating factor

Post operative

Symptoms same but

Vomitings invariable

Symptoms are persistent &severe

Severe alkalosis

Hypokalemia

Uremia

Gangrene&perforation of distended stomach


14/27

InvestigationsX-ray abdomen erect

dilatation of stomach&duodenum

little/no gas & air fluid levels in the distal bowel

USG abdomen

dilated stomach&duodenum upto D3

duplex scan can measure aortomesenteric angle


15/27

Barium meal screeningConstant dilatation of proximal duodenum with marked to&fro peristasisDelay in passage of contrast

Characteristic vertical linear extrinsic pressure defect in D3

disappearance of retention in prone position

Radiological evidence is most manifest during an attack

Absence of typical signs does not exclude diagnosis


16/27

Aortic and SMA angiography in conjunction with hypotonic duodenography

delineate aortomesenteric angle

can show crossing of SMA at the site of obstruction

CT scan with contrast &3D reconstruction

MRI


17/27

CT abdomen


18/27

Helical CT with contrast and 3D reconstruction


19/27

Differential diagnosis

Cysts&tumours of pancreas/duodenum

Enlarged lymphnodes at the base of the mesentery

Retroperitoneal neoplasms

Adhesions

Crohns disease affecting DJ region


20/27


21/27

Treatment

Conservative

Successful in orthopedic conditions

NG aspiration

Removal of cast, mobilisation of pt

Postural changes

IV alimentation

In chronic SMAS

advprone position after meals,

prokinetics


22/27

Operative managementIndications

failure of nutritional measures

malnutrition persists

wt loss continuesworsening symptoms

complicated peptic ulcer disease

Procedures

division of lig of treitz with/without mobilisation of duodenum

Anterior transposition of duodenum

Duodenojejunostomy with/without division of lig of treitz


23/27

DIVISION OF LIGAMENT OF TREITZ


24/27

ANTERIOR TRANSPOSITION OF DUODENUM


25/27

DUODENO JEJUNOSTOMY


26/27

CONCLUSIONS

In cases of high intestinal obstruction with the

presence of a dilated stomach and absent gas in the

small intestine, a high index of suspicion for SMA

syndrome should be entertained.

An abrupt cutoff at the third part of the duodenum

after an oral contrast and a decreased angle (6-16%)

between SMA and the aorta on CT-angiogram will confirmthe diagnosis.


27/27

Thanks for your attention !!

sma syndrome

Documents