1. Manifestations of Severe Malnutrition Juliana E. Reeves Oct. 15, 2004 ACR code 73.79

2. 29 yo F Presented to OSH on 9/15 with chronic abdominal pain, nausea, vomiting 2mo h/o 40 lb wt loss 1mo h/o plugged PEG Emaciated, mild abdominal tenderness, no rebound, skin breakdown around PEG LFT wnl except albumin of 1.6 and protein of 3.7 Lipids, Vit A & D and folate decreased

3. 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

4. Abdominal CT Sept. 19

5. Upper GI on Sept. 23

6. Radiographic Features & Differential Diagnosis Radiographic Features Marked hepatic steatosis (diffusely hypodense) by CT Scissoring of duodenum between aorta and SMA Narrowing of duodenum by upper GI Differential Diagnosis SMA syndrome/Wilkie’s syndrome Anorexia Nervosa Duodenal Obstruction Pancreatitis

7. Discussion First described by von Rokitansky in 1861 Compression of duodenum between aorta and SMA, leading to obstruction and dilatation Wasting diseases, rapid weight loss and extreme lordosis can contribute to its development Postprandial epigastric pain and fullness are relieved by vomiting Can simulate or complicate anorexia nervosa Occurs most commonly in young adult women

8. References Adson, 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.