Answer for BIR CoW 04 Oct 2020
SMA SYNDROME
Findings
CONVENTIONAL BARIUM MEAL STUDY:
Shows grossly distended stomach with dilated proximal duodenum.
1 hr delayed film shows distended stomach and duodenum and failure of distal flow of contrast.
CECT ABDOMEN:
Axial sections shows dilated stomach and first and second part of duodenum.
Compressed third part of duodenum between Aorta and Superior Mesenteric Artery.
Collapse of distal bowel loops.
Coronal section shows grossly dilated stomach.
MIP and 3D Reconstructed images shows
Decreased AMD (Aortomesenteric distance)- 5mm
Decreased AMA (Aortomesenteric angle)-15 degree
Discussion
SMA SYNDROME:
Also known as CAST SYNDROME, AORTICOMESENTRIC DUODENAL COMPRESSION SYNDROME or WILKIE SYNDROME
More common in Females than Males. The Common age at presentation is usually 10-40 yrs.
The patients usually present with Post-prandial epigastric pain, fullness, weight loss, anorexia and Pain relieved by lying prone or lateral decubitus position.
PATHOLOGY:
Obstruction of third part of duodenum between Anterior SMA and Posterior Aorta. Normally Retroperitoneal fat provides a cushion for the duodenum. Normal Aorto Mesenteric Distance is 10-34mm and Normal Aorto Mesent3ric Angle is 28-65 degree.
The causes of this syndrome are
Rapid and severe weight loss (cancer, acquired immunodeficiency syndrome, burns, major surgery, malabsorption etc)
Insertional variant of ligament of treitz or low origin of SMA.
Applied external abdominal pressure. (body or hip spica cast)
Patients undergone corrective surgery for scoliosis
RADIOLOGICAL INVESTIGATIONS:
1. BARIUM:
Shows dilated stomach and proximal duodenum, vertical extrinsic compression on the third part of duodenum, anti – peristaltic wave proximal to the obstruction and delayed gastro duodenal emptying,
There is relief of obstruction by positional change and in severe cases there is no distal flow of barium.
2. MULTI-DETECTOR CT: (late angiographic phase)
Reduced AMA and AMD and Compression of third portion of duodenum by the narrow angled origin of SMA from the Aorta.
Distended proximal duodenum and stomach due to obstruction.
Sagittal MPR images are used to evaluate AMA which will be decreased below normal
TREATMENT: Usually Conservative management is done and If it fails surgery can be done to relieve the obstruction.
Findings
CONVENTIONAL BARIUM MEAL STUDY:
Shows grossly distended stomach with dilated proximal duodenum.
1 hr delayed film shows distended stomach and duodenum and failure of distal flow of contrast.
CECT ABDOMEN:
Axial sections shows dilated stomach and first and second part of duodenum.
Compressed third part of duodenum between Aorta and Superior Mesenteric Artery.
Collapse of distal bowel loops.
Coronal section shows grossly dilated stomach.
MIP and 3D Reconstructed images shows
Decreased AMD (Aortomesenteric distance)- 5mm
Decreased AMA (Aortomesenteric angle)-15 degree
Discussion
SMA SYNDROME:
Also known as CAST SYNDROME, AORTICOMESENTRIC DUODENAL COMPRESSION SYNDROME or WILKIE SYNDROME
More common in Females than Males. The Common age at presentation is usually 10-40 yrs.
The patients usually present with Post-prandial epigastric pain, fullness, weight loss, anorexia and Pain relieved by lying prone or lateral decubitus position.
PATHOLOGY:
Obstruction of third part of duodenum between Anterior SMA and Posterior Aorta. Normally Retroperitoneal fat provides a cushion for the duodenum. Normal Aorto Mesenteric Distance is 10-34mm and Normal Aorto Mesent3ric Angle is 28-65 degree.
The causes of this syndrome are
Rapid and severe weight loss (cancer, acquired immunodeficiency syndrome, burns, major surgery, malabsorption etc)
Insertional variant of ligament of treitz or low origin of SMA.
Applied external abdominal pressure. (body or hip spica cast)
Patients undergone corrective surgery for scoliosis
RADIOLOGICAL INVESTIGATIONS:
1. BARIUM:
Shows dilated stomach and proximal duodenum, vertical extrinsic compression on the third part of duodenum, anti – peristaltic wave proximal to the obstruction and delayed gastro duodenal emptying,
There is relief of obstruction by positional change and in severe cases there is no distal flow of barium.
2. MULTI-DETECTOR CT: (late angiographic phase)
Reduced AMA and AMD and Compression of third portion of duodenum by the narrow angled origin of SMA from the Aorta.
Distended proximal duodenum and stomach due to obstruction.
Sagittal MPR images are used to evaluate AMA which will be decreased below normal
TREATMENT: Usually Conservative management is done and If it fails surgery can be done to relieve the obstruction.
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!