Loma Linda University Medical Center Loma Linda, CA, United States
Sneha Shaha, DO1, Yinglin Gao, DO1, James Huang, MD2, Eric Imbertson, MD2, Sherman Rhee, MD2, Cindy Cai, MD2 1Loma Linda University Medical Center, Loma Linda, CA; 2VA Loma Linda Healthcare System, Loma Linda, CA
Introduction: Superior mesenteric artery syndrome (SMAS) is a rare cause for proximal small bowel obstruction (PSBO) usually associated with weight loss. It features compression of the 3rd portion of the duodenum by SMA due to narrow aortomesenteric angle from loss of mesenteric fat pad. Patients with decompensated cirrhosis are highly susceptible to malnutrition. We report a case of SMAS in a cirrhotic patient treated with percutaneous endoscopic gastrojejunostomy (PEG-J).
Case Description/Methods: A 61year old Caucasian male with a history of alcoholic cirrhosis presented with a week of diffuse abdominal pain associated with nausea, vomiting, anorexia, and constipation after a 25 pound weight loss. His cirrhosis was complicated with esophageal varices, hepatic encephalopathy and refractory ascites treated successfully with a trans-jugular intrahepatic portosystemic shunt. His Model for End-Stage Liver Disease Sodium (MELD-Na) score on admission was 21 with a Child-Pugh (CP) class of C and serum albumin of 2.8. Contrast-enhanced computed tomography showed compression of the third portion of the duodenum with an aortomesenteric angle at 200. High-grade obstruction from the 2nd and 3rd portion of the duodenum without intraluminal lesions was confirmed during esophagogastroduodenoscopy (EGD). Besides conservative medical management, a 24 Fr PEG tube with a 12 Fr extension tube into the proximal jejunum was placed endoscopically through the guidewire under fluoroscopy. He recovered well with the gastric venting via G-port and enteral nutrition via J-port. Two months later, another EGD showed complete resolution of the obstruction, and G-J tube was pulled out. Patient has maintained adequate oral feeding with steady weight gain, and recent MELD-Na and CP class all back to his baseline of 12 and B, respectively.
Discussion: To our knowledge, this is the first reported SMAS in a cirrhotic patient. This case shed some light on early recognition of SMAS as a cause for PSBO in a cirrhotic patient with severe weight loss. If not treated promptly, this could result in significant morbidity and mortality. Medical management remains the primary treatment for SMAS with a goal of gastric decompression, fluid resuscitation, correction of electrolytes and reversal of weight loss by enteral or parenteral nutrition. PEG-J provides a safe and effective treatment for SMAS with both gastric decompression and post-duodenal nutritional support.
Sneha Shaha indicated no relevant financial relationships.
Yinglin Gao indicated no relevant financial relationships.
James Huang indicated no relevant financial relationships.
Eric Imbertson indicated no relevant financial relationships.
Sherman Rhee indicated no relevant financial relationships.
Cindy Cai indicated no relevant financial relationships.
Sneha Shaha, DO1, Yinglin Gao, DO1, James Huang, MD2, Eric Imbertson, MD2, Sherman Rhee, MD2, Cindy Cai, MD2. P1840 - Successful Treatment of Superior Mesenteric Artery Syndrome in a Cirrhotic Patient with Percutaneous Endoscopic Gastrojejunostomy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.