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Cases
Chronic Abdominal Pain in a 30-Year-Old Man
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Background
A 30-year-old white man presents to the
emergency department with intermittent
episodic discomfort in the upper abdomen that
has lasted more than 10 years. Although the
episodes are frequently severe and last
several hours to 2 days, they resolve
spontaneously. The patient reports no
exacerbating factors, and weeks and months
can pass between episodes. He is completely
asymptomatic between these events. Nausea,
occasional bloating, and nonbilious emesis are
associated with the episodes. The patient's
bowel pattern is normal, without hematochezia,
and he has had no weight loss or fevers.
Results of multiple evaluations in the past,
including upper endoscopy and upper
gastrointestinal contrast studies, have been
normal.
The review of systems is otherwise
unremarkable. The patient works in an office
and does not smoke or drink. He takes no
medications and has no allergies. The patient
underwent laparoscopic cholecystectomy in the
past and once had a hip fracture from a fall.
On examination, the patient is markedly
uncomfortable. Abdominal palpation reveals
tenderness in the epigastrium with guarding
but no rebound. No masses or organomegaly are
detected. Bowel sounds are normal. Findings on
rectal examination are normal, with no masses
and heme-negative brown stool. The patient's
vital signs, remaining physical findings, and
laboratory values are normal.
What is the diagnosis?
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Scroll down for Hint and Answer
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***** HINT *****
Abdominal CT is helpful in establishing the diagnosis.
***** ANSWER *****
Superior mesenteric artery syndrome: The abdominal
CT scan shows marked dilatation of the proximal
duodenum. At the level of the superior mesenteric
artery (SMA), the third part of the duodenum is
narrowed. The duodenum is compressed by a sharp
aortomesenteric angle as it passes between the SMA
and aorta, resulting in SMA syndrome. The distal
duodenum appears normal in caliber. Initially
recognized by Von Rokitansky in 1861, SMA syndrome
is an uncommon cause of chronic, intermittent, or
acute complete or partial duodenal obstruction.
Often a diagnostic dilemma, this entity is a
diagnosis of exclusion.
The patient was referred for elective surgical
evaluation to discuss his candidacy for laparoscopic
jejunostomy bypass.
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Author:
Benjamin Wedro, MD
Department of Emergency Medicine, Gundersen Clinic, La Crosse, Wisconsin; Clinical Professor, Department of Medicine, University of Wisconsin
eMedicine Editor:
Sat Sharma, MD
Associate Professor, University of Manitoba, Department of
Medicine, Division of Pulmonary Medicine
Source
http://emedicine.com
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