Superior Mesenteric Artery Syndrome Diagnosed with Linear Endoscopic Ultrasound (with Video) in a Patient with Normal Body Mass Index
A 61-year-old female visited the emergency room complaining of sudden abdominal pain and nausea after overeating. She visited a local clinic where she underwent abdominal CT and was prescribed an analgesic, but the pain did not subside, so she visited our hospital. Her medical and social histories were noncontributory. At admission, her blood pressure was 120/80 mm Hg, pulse rate 68 per minute, respiratory rate 18 per minute, body temperature 36.9℃, height 157 cm, weight 50 kg, and BMI 20.3. She denied a history of weight loss. The physical examination revealed an acutely ill-looking appearance with epigastric tenderness. The complete blood count showed leukocytes 10,600/µL, hemoglobin 13.3 g/dL, and platelet count 208,000/µL. The blood chemistry showed total bilirubin 0.5 mg/dL, aspartate aminotransferase 18 U/L, alanine aminotransferase 13 U/L, amylase 106 U/L, blood urea nitrogen 23 mg/dL, creatinine 0.67 mg/dL, and C-reactive protein 0.26 mg/dL.\nThe initial abdominal X-ray revealed a large amount of food distending the stomach and mild gas accumulation in the small and large bowel (). An abdominal CT taken at the local clinic showed a hugely distended stomach and duodenum (). The aortomesenteric distance on CT was 7.4 mm which was decreased than normal mean aortomesenteric distance of 10 to 28 mm in healthy people. Conventional barium studies, which still play an important role for diagnosis of SMA syndrome, could not be performed because of severe gastroptosis and distended stomach. Then we performed esophagogastroduodenoscopy (EGD) and EUS to rule out intestinal intraluminal obstruction and gastric or duodenal ulcer disease that might be secondary to reflux or that might constitute a primary pathology mimicking SMA syndrome. EGD revealed a huge amount of food in the stomach (). Since that EUS could give us more information about surrounding organs which can directly compress the duodenum, we performed linear EUS (EG3870-UTK; Pentax, Tokyo, Japan). This did not show any abnormality of the gallbladder, common bile duct or pancreas. However, it showed the SMA running almost parallel to the abdominal aorta, with an aortomesenteric angle of 10° (normal range, 38° to 65°), confirming the diagnosis of SMA syndrome (, Supplementary Video 1 [available online at ]). The patient was managed conservatively with bowel rest and intravenous fluids. The abdominal pain and nausea were relieved and the patient started a soft diet on day 5 of admission and was discharged on day 7 of admission without any symptoms.