ARJ
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A 55-year-old woman was referred to surgery department complaining of early satiety, nausea, and vomiting of partially digested food. These symptoms had been increasing over the past 2 years and had substantially worsened over the past 3 months. She also reported epigastric fullness especially after meals, which improved after vomiting. Her weight was 134 lbs and height was 5 feet 7 inches. She denied rapid weight loss, fever, or change in bowel habits. Her medical history was remarkable for scleroderma, dysphagia due to esophageal stricture, Raynaud's syndrome, congestive heart failure, and degenerative joint disease.Computed tomography (CT) of the abdomen revealed dilatation of the second portion of the duodenum.Esophagogastroduodenoscopy showed a dilated second portion of the duodenum extending approximately 10 cm distal to the pylorus, and it was filled with partially digested food. Erosive esophagitis and esophageal stricture were also identified ??????????
Whats the Diagnosis.....................
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| drkpp
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CREST!!!!!!!!!!
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| Renegade
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Hnn, I don't know. Lacks telangiectasia and usually there is rapid weight loss. Can we order some tests?  Or at least know of any stool changes, if «scleroderma» was proximal/distal, or if there were any organomegs.
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| chemamr
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any other data can enlighten us.
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| ARJ
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Hey Chemanr you gonna blow his knee
Hint---now the diagnosis would be easy------
The symptoms are typically relieved when the patient is in the left lateral decubitus, prone, or knee-to-chest position, and they are often aggravated when the patient is in the supine position.
More common in patient with an asthenic habitus..................
Edited by ARJ on 10/31/05 - 10:43 PM
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| ARJ
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Atleast try
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| Renegade
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I've been rsxing, and your hint suggests mesenteric artery syndrome... however, pt denied rapid weight loss, apparently there's no familiar component, and... has Raynaud or CHF anything to do with it? 
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| drkpp
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some kind of connective tissue disorder???????
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| chemamr
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Jesus!, this is very dark. I have no a clear idea of the dx (We know she has a scleroderma. but besides that).
any obstruction in the 3rd portion of the duodenum, near treitz. Any carcinoma there? ( i know she denies any weight loss, but ??).
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| ARJ
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Now I have to give it away..........Renegade got it right.............Good try drkpp.chemanr
Actually it was difficult...........Superimposed on Scleroderma. Almost similar case experience but had to refer to a tertiary centre because of the lack of knowledge....................................
Superior mesenteric artery (SMA) syndrome is an uncommon but well recognized clinical entity characterized by compression of the third, or transverse, portion of the duodenum against the aorta by the SMA, resulting in chronic, intermittent, or acute complete or partial duodenal obstruction. SMA syndrome was first described in 1861 by Von Rokitansky, who proposed that its cause was obstruction of the third part of the duodenum as a result of arteriomesenteric compression. Despite the fact that about 400 cases are described in the English language literature, many have doubted the existence of SMA syndrome as a real entity; indeed, some investigators have suggested that SMA syndrome is overdiagnosed because it is confused with other causes of megaduodenum. Nonetheless, the entity often poses a diagnostic dilemma; its diagnosis frequently is one of exclusion.
The SMA usually forms an angle of approximately 45° (range, 38-56°) with the abdominal aorta, and the third part of the duodenum crosses caudal to the origin of the SMA, coursing between the SMA and aorta. Any factor that sharply narrows the aortomesenteric angle to approximately 6-25° can cause entrapment and compression of the third part of the duodenum as it passes between the SMA and aorta, resulting in SMA syndrome. In addition, the aortomesenteric distance in SMA syndrome is decreased to 2-8 mm (normal is 10-20 mm). Alternatively, other causes implicated in SMA syndrome include high insertion of the duodenum at the ligament of Treitz, a low origin of the SMA, and compression of the duodenum due to peritoneal adhesions.
History: The patient often presents with chronic upper abdominal symptoms such as epigastric pain, nausea, eructation, voluminous vomiting (bilious or partially digested food), postprandial discomfort, early satiety, and sometimes, subacute small-bowel obstruction. The symptoms are typically relieved when the patient is in the left lateral decubitus, prone, or knee-to-chest position, and they are often aggravated when the patient is in the supine position.
Physical: An asthenic habitus is noted in about 80% of cases. Abdominal examination may reveal a succussion splash. Peptic ulcer disease has been noted in 25-45% of the patients, and hyperchlorhydria has been noted in 50%. Patients can present with signs of subacute small-bowel obstruction.
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| chemamr
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 that was hard to know. Thank you for the new data.
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