MAY,

197.3

SUPERIOR
By DONALD H. ALTMAN,

MESENTERIC ARTERY IN CHILDREN*

M.D.,t and SUBHASH
MIAMI, FLORIDA

SYNDROME
M.B., M.S., F.R.C.S.(C)

R.

PURANIK,

in clinical diagnosis of obstruction in the third part of the duodenum by the superior mesenteric artery are well known.4 Roentgenognaphy is the most valuable aid in the diagnosis and follow-up of these cases. Seven cases occurring from 1961 to 1971 at the Variety Childrens Hospital are reported.
CLINICAL MATERIAL of

HE difficulties

mass

and

its

fixation

by

adhesions

was

be-

lieved to mesentenic

result vessels

in

pull on the (Fig. 4, .4 and

FINDINGS

superior B).

ROENTGENOLOGIC

The gastnoi helpful

struction

diagnosis should be made by upper ntestinal examination. The most noentgenobogic sign is a line of obin

the

third

pant towards
to

of the the
the

duodenum right
course

passing
quadrant

obliquely
corresponding

lower
of the

Table
in these

I is

a summary

the
first

case
4 cases

histories
nepre-

superior tion complete may

mesentenic be total in obstruction,

vessels.4 acute other

The forms. changes

obstnucIn less have

7 patients.

The

sent acute obstruction.5 Cases I and II developed the duodenal obstruction following Harnington Rod instrumentation and spinal fusion for idiopathic scoliosis (Fig. i, 11 and B). Both were immobilized postoperatively in a bivalved body cast. The anterior half was removed during the trial of conservative management of their duodenal obstructions. Case III developed the duodenal obstruction during nonopenative management of her kyphoscoliosis. All these 3 cases required surgical intervention. In Case iv (Fig. 2) acute increase of lordosis following hamstring tenotomy was the
likely etiologic factor. Correcting the br-

to be canefull looked dilated first 3 portions delay in the passage

for.
of

Dilated
the

stomach,
or

duodenum

of barium
midline or to and

through
should fro activity

the
raise

duodenum suspicion.

across Churning

the

of barium denum and

diagnostic

in the reverse
signs,

third pant of the duopenistalsis are additional

and are best appreciated

by

fluoroscopy.3

TV

videotape
in diagnosis at follow-up. in of from the methods
feasible.

recording
and is Some obresupine position may
In
seen

will add to the accuracy useful for evaluation barium structions. tention position will
in treatment

may by

pass through Disappearance tilting that pathology position. sideways change these
whenever

partial duodenal the

dosis relieved his arteniomesentenic duodenal compression. The last 3 cases represent the chronic form of obstruction. They all had abdominal pain and 2 had vomiting. Partial duodenal obstruction due to compression of its third pant by the superior mesentenic artery as it crosses the duodenum was the cause of symptoms in these cases (Fig. 3, 1 and B).
Case weight
*

on by suggest the

to

prone

help
some
in

cases, the
ture of

may The

be

only

supine the and

intermittent

nain

mind

obstruction should be kept studies repeated in suspicious

VII

is very unusual. of a duplication

at the
Departments

In as
Annual

this a

patient mesenteric
of the Society

the

cases.3 Some chronic forms may have associated peptic ulcer disease,7 and evidence of duodenal and/on gastric ulceration should be looked for. We have not found it necesfor Pediatric
Childrens

Presented
the

Fifteenth
of

Meeting
and Pediatric

Radiology,
Hospital,

Washington,
Miami,

D.
Florida.

C.,

October

I-I,

1972.

From

Radiology

Surgery,

Variety

t
School

Director of Radiology, of Medicine, Miami, Instructor in Pediatric

Variety Florida. Surgery,

Childrens Variety

Hospital Childrens

and Hospital,

Clinical Miami, 104

Professor Florida.

of

Radiology

and

Pediatrics,

University

of

Miami

VOL.

118,

No.

Superior

Mesenteric
TABLE

Artery
I

Syndrome

105

SUMMARY

OF

CASE

HISTORIES

OF

7 CASES

OF SUPERIOR

MESENTERIC

ARTERY

SYNDROME

Case No.

Sex! Age

Date of 1st . Admission May 1964

History

and Physical . . Findings

Roentgenographic . . Findings Duodenal the 3rd obstruction part in

Treatment

Outcome

M/i9

Vomiting Ii days postHarrington Rod instrumentation and spinal fusion for scoliosia and postoperative body cast; continued vomiting after 1st procedure

Division ofligament of Treitz and lowering the duodenojejunal junction Duodenojejunostomy

No

relief

Persistent

obstruction

Recovered confirmed ically Recovered logically

clinically and roentgenolog-

II

F/io

May

1971

Vomiting Harrington mentation fusion for postoperative

days postRod instruand spinal scoliosis and body cast

Duodenal in the 3rd

obstruction part

Duodenojejunostomy

and

roentgenoclinically

III

F/z

June

1961

Spinal kyphoscoliosis under conservative management and awaiting surgery; developed vomiting suddenly 1968 Cerebral palsy with spasticityofboth lower extremities; multiple tenotomies including the hamstring muscles with long leg casts Abdominal vomiting asthenic Colicky pains for pain for build
2

Duodenal in the 3rd

obstruction part

Duodenojejunostomy

Recovered logically and

roentgenoclinically

IV

M/I9

November

Partial struction part

duodenal in the

ob3rd

Reduction ofspinal dosis by keeping in flexed position in bed

brhips when

Recovered logically

and

roentgeno.. clinically

F/io

January

1969

and years;

Duodenal in the 3rd

obstruction part

Conservative-frequent small high caloric ings

feed-

Recovered logically

and

roentgenoclinically

VI

M/9

February

1967

abdominal

Duodenal in the 3rd

obstruction part

Conservative-frequent small ings ob3rd high caloric feed

month

Recovered logically

and

roentgenoclinically

VII

M/6

February

1965

J ejunal

duplication with intrathoracic cxtension removed by transthoracic approach at 3 months; abdominal pain and vomiting from e,rly childhood

Partial struction part

duodenal in the

Exploratory omy, excision duplication, and mesentery

laparotof large jejunum

Recovered logically

and

roentgenoclinically

sary diagnosis.

to

resort

to

angiography

as

an

aid

to

DISCUSSION

Acute forms ofsuperior mesentenic artery obstructions have also been called the Cast Syndrome. However, the latter term also includes primary gastric paralysis from body casting.6 Roentgenography of the upper gastrointestinal tract is the only means of distinguishing between the two. The acute form occurring in the course of the treatment for scoliosis2 is a problem of

particular importance in children. The acute obstruction can also occur in other conditions like exaggeration of lordosis or prolonged recumbency, etc. The clinical course of our patients had paralleled the roentgenologic findings. Persistent near total obstruction as evidenced by serial gastrointestinal series suggests that it is futile to persist with conservative measures. This was well illustrated in the first 3 cases. The chronic form of superior mesenteric artery syndrome in children is a more oh-

o6

Donald

H.

Altman

and

Subhash

R.

Punanik

MAX,

1973

11G.

I.

Case it. (A) for correction

Gastric dilatation of scoliosis. (B)

and acute Relief of

duodenal
obstruction

obstruction 10 days

following Harrington following duodenojejunostomy.

Rod

insertion

scure

disease.

Tile

obstructions is
upper

are more our as

cases is

usually difficult. hospital,

not

total u

and had
prior

diagnosis

Case
studies which

several
to

gastrointestinal

referral interpreted
in

to

were

all
role

normal.
to

The
estab-

radiologists

these

lish
by

a diagnosis
determining

and the to follow

help
the

plan
value role

management
of of positional conserva-

changes,
tive

and and

operative

management.
CO N C LU S ION

In our
of the

series

of

cases

success

or

failure

management

was

well

demonstrated

by

roentgenognaphy.

11G.

2. Case iv. Massive gastric dilatation with food and fluid retention and duodenal dilatation in a 19 year old cerebral palsy patient following hamstring tenotomy.

0#{149}
0

108

Donald

H.

Altman

and

Subhash

R. Puranik

MAY,

1973

Persistent obstructions demonstrated roentgenobogically correlated with persisting pain and vomiting, and relief of obstruction paralleled clinical recovery.
Donald H. Altman, M.D. Variety Childrens Hospital Mami, Florida 33155

3. GOIN,

Surg., 1971,53-il, 43i-44 and 497. L. S., and WILK, S. P. Intermittent

arterio-

mesenteric
1956, 4. SMITH,

occlusion
729-737.

of duodenum.

Radiology,

67, M.

P. E., ZIPERMAN, H. H., and L. Infrapapillary obstruction of duodenum. Ann. Surg., 1961, 154, 125-132. 5. KAISER, G. C., MCKAIN, J. M., and SHUMACKER,
HARTENSTEIN,

H. B.,
Surg., 6. review England of litera7. Med.,
KAUFFMAN,

JR.

Superior

mesenteric
1960,

artery
110,

syndrome.
133-140.

Gynec.

REFERENCES
i. DORPH,

ture

M. H. Cast syndrome: and report of case. New

1950,243,440-442.

EVARTS,

Vascular

with

C. M., WINTER, R. B., and HALL, J. E. compression of duodenum associated treatment of scoliosis. 7. Bone & 7oint

F. Arterioof three cases, one of which followed application of body cast. Stanford M. Bull., 1951, 9, 262-272. 7. WILLIAMS, L. F., and BOWERS, W. F. Arteriomesenteric duodenal obstruction associated with severe peptic ulcer diseases. Ann. Surg.,
GERBODE,

& Obst., R. R., and

mesenteric

duodenal

ileus:

report

1961,

153,

250-255.