Manifestations of Severe Malnutrition

Juliana E. ReevesOct. 15, 2004

ACR code 73.79

29 yo F Presented to OSH on 9/15 with chronic abdominal pain, nausea, vomiting2mo h/o 40 lb wt loss 1mo h/o plugged PEGEmaciated, mild abdominal tenderness, no rebound, skin breakdown around PEGLFT wnl except albumin of 1.6 and protein of 3.7

Lipids, Vit A & D and folate decreased

Past Medical History

9 yr h/o chronic abdominal pain, with intermittent nausea and vomiting

s/p Laparoscopy Jan. 1999

s/p Lap Chole and Appy in 2000

s/p PEG tube placement Feb. 2002

Prior records show a possible diagnosis of irritable bowel syndrome, multiple medications provided no relief

Abdominal CT Sept. 19

Upper GI on Sept. 23

Radiographic Features & Differential Diagnosis

Radiographic FeaturesMarked hepatic steatosis (diffusely hypodense) by CTScissoring of duodenum between aorta and SMANarrowing of duodenum by upper GI

Differential DiagnosisSMA syndrome/Wilkie’s syndromeAnorexia NervosaDuodenal ObstructionPancreatitis

Discussion

First described by von Rokitansky in 1861Compression of duodenum between aorta and SMA, leading to obstruction and dilatationWasting diseases, rapid weight loss and extreme lordosis can contribute to its developmentPostprandial epigastric pain and fullness are relieved by vomitingCan simulate or complicate anorexia nervosaOccurs most commonly in young adult women

ReferencesAdson, David E et al. The Superior Mesenteric Artery Syndrome and Acute Gastric Dilatation in Eating Disorders: A Report of Two Cases and a Review of the Literature. International Journal of Eating Disorders 1997; 21:103-14.Kwan, Eugene et al. Wilkie’s Syndrome. Surgery 2004; 135:225-7.Lim, Jonathon E et al. Superior Mesenteric Artery Syndrome Presenting with Acute Massive Gastric Dilatation, Gastric Wall Pneumatosis, and Portal Venous Gas. Surgery 2003; 134:840-3.Payawal, Jonathon H et al. Superior Mesenteric Artery Syndrome Involving the Duodenum and Jejunum. Emergency Radiology 2004; 10:273-5.