Upload
nawneet-kumar
View
217
Download
0
Embed Size (px)
Citation preview
7/31/2019 SMA Syndrome
1/27
SUPERIOR MESENTERIC ARTERYSYNDROME
Dr.P. Naga Raja
Pg,Dept of gen .surg, CAIMS
7/31/2019 SMA Syndrome
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
7/31/2019 SMA Syndrome
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.
7/31/2019 SMA Syndrome
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.
7/31/2019 SMA Syndrome
5/27
dilated 2nd part of the duodenum retrocolic passage for mobilized jejunum
side to end duodeno-jejunal anastamosis
7/31/2019 SMA Syndrome
6/27
end to side jejuno-jejunal anastamosis
passage of the contrast in to the
jejunum from the duodenum
7/31/2019 SMA Syndrome
7/27
Superior mesenteric artery syndrome
7/31/2019 SMA Syndrome
8/27
TERMINOLOGY
Chronic duodenal ileus
Vascular compression of the duodenum
Gastromesenteric ileus
Arteriomesenteric duodenal compression syndrome
Wilkies disease
SMA syndrome
cast syndrome
7/31/2019 SMA 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
7/31/2019 SMA Syndrome
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
7/31/2019 SMA Syndrome
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
7/31/2019 SMA Syndrome
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
7/31/2019 SMA Syndrome
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
7/31/2019 SMA Syndrome
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
7/31/2019 SMA Syndrome
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
7/31/2019 SMA Syndrome
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
7/31/2019 SMA Syndrome
17/27
CT abdomen
7/31/2019 SMA Syndrome
18/27
Helical CT with contrast and 3D reconstruction
7/31/2019 SMA Syndrome
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
7/31/2019 SMA Syndrome
20/27
7/31/2019 SMA Syndrome
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
7/31/2019 SMA Syndrome
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
7/31/2019 SMA Syndrome
23/27
DIVISION OF LIGAMENT OF TREITZ
7/31/2019 SMA Syndrome
24/27
ANTERIOR TRANSPOSITION OF DUODENUM
7/31/2019 SMA Syndrome
25/27
DUODENO JEJUNOSTOMY
7/31/2019 SMA Syndrome
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.
7/31/2019 SMA Syndrome
27/27
Thanks for your attention !!