Superior mesenteric artery syndrome

Syndrome superior mesenteric artery is also known as duodenal compression arterio-mesenteric , chronic duodenal stasis , Rokitansky syndrome , syndrome Wilkie , of plastering syndrome or aortomesenteric impingement .

Summary

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  • 1 Terminology
  • 2 Symptoms
  • 3 Treatment
  • 4 Sources

Terminology

This is due to intermittent compression of the third portion of the duodenum, due to abnormal birth of the superior mesenteric artery. The main causes lie in the sharpness of the angle of emergence in the aortic artery and the short length until it crosses the third portion of the duodenum.

This disease was described in 1752 by Boerneus , by means of necropsy findings; a century later, Rokitansky considered it the etiological factor of duodenal obstruction. In 1891, Kundrat asserted that incomplete obstruction of the duodenum was due to compression of the root of the mesentery. Soutcler was the first to attribute lordosis an important role in the occurrence of duodenal ecstasy. In 1900, Robinson found , by autopsy, that the superior mesenteric vessels caused compression of the duodenum with dilation of the proximal portion.

They were Baker and Finney who established a relationship between dilatation of the duodenum and postoperative gastric disorders and first spoke of duodenojejunostomy method of treatment in these patients.

In 1907 Bloodgood suggested its use in daily medical practice, and the first successful surgical intervention was performed by Stavely in 1908, at Johns Hopkins Hospital. Between 1920 and 1930, the indications and diagnostic criteria were not yet clearly defined, so the final therapeutic results were not desired, and only 4 cases were published between 1934 and 1950.1-3 In the 1960s, combined arteriograms were performed with a contrast examination of the upper part of the digestive tract to locate the site of the obstruction. New paraclinical investigations have been developing since the end of the last century; These include abdominal ultrasound, computed axial tomography , and magnetic resonance angiography of the abdomen., which re-emerge the diagnosis of this disease.

Due to the rotation of the intestine during fetal life, the descending, transverse and ascending portions of the duodenum become retroperitoneal, at the distal end of which the Treitz ligament ends ; The vena cava, the vertebral bodies and the aorta artery join it behind; Ahead crosses the root of the mesentery. The descending portion is located in the right paravertebral canal, slightly behind the vertebral bodies, which makes the other 2 portions follow a transverse path over the rigid retroperitoneal organs.

Normally, the superior mesenteric artery branches off from the aortic artery at an average angle between 30 and 42 ° to the first lumbar vertebra. The distance from this angle to the midpoint of the duodenum is approximately 10 cm. According to some authors, 3,4,6 the most important mechanical obstructive factors are the combination of the existence of a fixed duodenum attached to an acute clearance angle of the superior mesenteric artery or an abnormal arterial path above the vertebral bodies.

Its true incidence is difficult to assess, but it has occurred more frequently in males.

Symptoms

Patients may have a history of colicky abdominal pain and nausea, which is alleviated by vomiting, which is bilious, sometimes food. The acute form often appears in isolated patients due to chronic diseases, trauma, prolonged application of plaster splints, among other causes. In the chronic form, there are marked epigastric discomfort, vomiting or not, asthenia, general weakness and weight loss. In both cases, the physical examination provides little data, and the most striking are epigastric discomfort with palpation and the decrease in subcutaneous cell tissue.

The presence of the disease is suspected by the clinical picture. Laboratory investigations show a drop in hemoglobin and total plasma protein levels. Among the imaging studies, the simple abdomen study may suggest the diagnosis (especially in the acute forms), since significant gastric and duodenal bloating is observed. There is no gas in the distal duodenum.

The radiological study of the esophagus, stomach and duodenum is of great value; there is great dilation of the first and second portions of the duodenum, in the midline or immediately to the right of the site of the obstruction. The dilation of the initial portion of the duodenum can reach 4.8 cm. The distal duodenum is normal in size, although classic radiological signs such as proximal dilatation of the duodenum, delay in the passage of the contrast agent and oblique defects in its distribution are also important for diagnosis. In cinefluoroscopy there are reciprocating peristaltic waves, back and forth. The abdominal ultrasound shows a markedly dilated duodenum, with food remains. Magnetic resonance imaging and angioresonance imaging show vascular abnormalities and the site of the obstruction.

The differential diagnosis is made with diseases as frequent as gastric and duodenal ulcers, acute cholecystitis, acute pancreatitis, irritable colon and pyloric syndrome, among others. Medical treatment consists of making the patient improve his body weight, so that fat accumulates in the retroperitoneum. Symptoms improve with the use of parenteral hyperalimentation and the use of the prone or left lateral position after meals to aid emptying.

Treatment

There are several surgical techniques described as a form of treatment:

– The division of the Treitz ligament, which is not highly recommended due to the firm consistency of this ligament.

– Change of position of the duodenum. This method does not invade the digestive tract and is useful in children.

– The duodenojejunostomy has satisfactory results and an 80-85% effectiveness; It is the most widely used method.

 

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