Mega-Stomach as a Result of Superior Mesenteric Artery Syndrome : ACG Case Reports Journal

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Mega-Stomach as a Result of Superior Mesenteric Artery Syndrome

Lee, Byung K. BS1; Hashem, Nasser DO2; Cho, Jonathan J. MD, PhD3; Lee, Maunoo MD4; Liu, Scott MD4; Drenckhahn, Jeremy T. MD5; Swaney, Sean M. DO5; Montgomery, Richard S. MD5; Berge, Michael J. MD5

Author Information

1F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD

2Internal Medicine Residency Program, Scripps Clinic and Scripps Green Hospital, La Jolla, CA

3Department of Internal Medicine, Naval Medical Center San Diego, San Diego, CA

4Department of Gastroenterology, Naval Medical Center San Diego, San Diego, CA

5Department of Radiology, Naval Medical Center San Diego, San Diego, CA

Correspondence: Jonathan J. Cho, MD, PhD ([email protected]).

Disclaimer: The authors have no funding or other disclosures. The authors are military service members or employees of the US Government. This work was prepared as part of their official duties. Title 17, U.S.C. § 105 provides that copyright protection under this title is not available for any work of the US Government. Title 17, U.S.C. § 101 defines a US Government work as work prepared by a military service member or employee of the US Government as part of that person's official duties. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the US Government.

ACG Case Reports Journal 10(3):p e01005, March 2023. | DOI: 10.14309/crj.0000000000001005
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CASE REPORT

A previously healthy 19-year-old man with no medical or surgical history presented with severe generalized abdominal pain associated with nausea and vomiting for 1 week. The patient was undergoing intensive strenuous training during the previous month resulting in a 20 lbs (9 kg) weight loss. His weight was 54.9 kg with a body mass index of 17.4 on the initial examination. Computed tomography showed severe gastric distention (Figure 1) and the aortomesenteric angle and distance of 13.8° and 4.5 mm, respectively (Figure 2), which are consistent with superior mesenteric artery (SMA) syndrome. Esophagogastroduodenoscopy was performed using a SIF-180 scope (200 cm) to traverse to 60 cm from the pylorus. A Cook NJFT-10 240 cm feeding tube with a suture ring was passed through the left nostril into the stomach, grasped with a hemoclip by the suture ring, and dragged past the area of external compression because of lack of insufflation in the stomach. A hemoclip was then closed with the suture loop 15 cm distal to the area of external compression. The hemoclip was exchanged with the SIF-180 scope withdrawal 1:1 until the duodenal bulb and deployed. Computed tomography after esophagogastroduodenoscopy showed the placement of the nasojejunal tube, which extended beyond the SMA to the duodenal-jejunal junction (Figure 3). Under the care of a registered dietitian nutritionist and enteral tube feed, he gained 10 kg within 4 weeks, leading to the resolution of his SMA syndrome (Figure 4), and tolerated oral intake for 9 days before the removal of the nasojejunal tube. He was instructed to maintain a body mass index of at least 21 kg/m2, continue a balanced diet, and follow up with a primary care physician.

F1
Figure 1.:
Abdominal/pelvic computed tomography with intravenous contrast shows severe gastric distention.
F2
Figure 2.:
Sagittal reconstruction of computed tomography at presentation demonstrating an aortomesenteric angle of 13.8° and an aortomesenteric distance of 4.5 mm. The stomach is markedly distended with fluid and dependent on ingested contents with the greater curvature of the stomach extending below the level of the image. This distended state is secondary to obstruction at the level of the third portion of the duodenum. Minimal subcutaneous fat is present.
F3
Figure 3.:
Sagittal reconstruction of computed tomography 2 days later shows interval placement of the nasojejunal tube (yellow arrow), which passes the obstruction in the duodenum. Gastric distension has resolved. The aortomesenteric angle and the aortomesenteric distance are improved at 35.1° and 8.1 mm, respectively.
F4
Figure 4.:
Follow-up computed tomography 1 month later demonstrates continued improvement of the aortomesenteric angle and aortomesenteric distance measuring to be 42.1° and 12 mm, respectively. The nasojejunal tube remains in place. Note the increase in the subcutaneous fat.

The patient in this case did not have chronic medical1,2 or psychological3 disorders or surgeries4,5 that increased his risk of SMA syndrome except for an intense exercise regimen and weight loss. This case highlights the utility of a well-anchored nasojejunal tube for the management of SMA syndrome. It also queries the need for further epidemiological study on the incidence and prevalence of SMA syndrome in a previously healthy population that develops weight loss after starting an intense exercise regimen, such as military or athletic training, and ways to prevent the development of SMA syndrome in such a population.

DISCLOSURES

Author contributions: All authors were involved in patient care, data collection, and wrote the manuscript. All authors approved the final draft submitted. JJ Cho is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case repot.

REFERENCES

1. Agarwal T, Rockall TA, Wright AR, Gould SWT. Superior mesenteric artery syndrome in a patient with HIV. J R Soc Med. 2003;96(7):350–1.
2. Salehzadeh F, Samadi A, Mirzarahimi M. Superior mesenteric artery syndrome in a 6-year-old girl with final diagnosis of celiac disease. Case Rep Gastrointest Med. 2019;2019:3458601.
3. Mascolo M, Dee E, Townsend R, Brinton JT, Mehler PS. Severe gastric dilatation due to superior mesenteric artery syndrome in anorexia nervosa. Int J Eat Disord. 2015;48(5):532–4.
4. 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(7):1008–11.
5. Adams JB, Hawkins ML, Ferdinand CH, Medeiros RS. Superior mesenteric artery syndrome in the modern trauma patient. Am Surg. 2007;73(8):803–6.
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