eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Superior Mesenteric Artery Syndrome: Treatment & Medication

Author: Shervin Rabizadeh, MD, MBA, Pediatric Gastroenterologist, Cedars Sinai Medical Center; Instructor, Department of Pediatrics, University of California, Los Angeles, David Geffen School of Medicine
Contributor Information and Disclosures

Updated: Jun 18, 2009

Treatment

Medical Care

Reversing or removing the precipitating factor is usually successful in a patient with acute superior mesenteric artery (SMA) syndrome. Conservative initial treatment is recommended in all patients with superior mesenteric artery syndrome; this includes adequate nutrition, nasogastric decompression, and proper positioning of the patient after eating (ie, left lateral decubitus, prone, or knee-to-chest position). Enteral feeding using a double lumen nasojejunal tube passed distal to the obstruction under fluoroscopic assistance is an effective adjunct in treatment of patients with rapid severe weight loss and also eliminates the need for intravenous fluids and the risks associated with total parenteral nutrition.

In some instances, both enteral and parenteral nutritional support may be needed to provide optimal calories. The patient's weight should be monitored daily. Subsequently, the patient can be started on oral liquids followed by slow and gradual introduction of small and frequent soft meals as tolerated. Finally, regular solid foods are introduced. Metoclopramide treatment may be beneficial. Review of the orthopedic literature reveals that the success rate is 100% with medical management only in cases with an acute presentation of superior mesenteric artery syndrome.

Surgical Care

Surgical intervention is indicated when conservative measures are ineffective, particularly in patients with a long history of progressive weight loss, pronounced duodenal dilatation with stasis, and complicating peptic ulcer disease. Duodenojejunostomy is the most frequently used procedure, and it is successful in about 90% of cases.5,6 The use of laparoscopic surgery that involves lysis of the ligament of Treitz and mobilization of the duodenum has been reported.

Consultations

The following consultations may be indicated:

  • Pediatric gastroenterologist
  • Nutritionist
  • Pediatric surgeon

Diet

Medical therapy usually begins with the initiation of intravenous fluids, with the frequent administration of small amounts of liquids. In some cases, nasogastric tube feedings with a standard liquid diet may be indicated.

Medication

Drug therapy currently is not a component of the standard of care for this syndrome. Metoclopramide may be used to provide a prokinetic effect.

Prokinetic agents

These stimulate motility of the GI tract. GI smooth muscle is regulated by autonomic innervation, local reflexes, and hormones. Peristalsis is induced and causes the gut contents to move, encouraging digestion.


Metoclopramide (Reglan, Clopra)

Dopamine antagonist that stimulates acetylcholine release in the myenteric plexus. Acts centrally on chemoreceptor triggers in the floor of the fourth ventricle, causing important antiemetic activity.

Adult

5-10 mg PO ac and hs

Pediatric

6-14 years: 0.1-0.2 mg/kg PO qd/bid/tid/qid; not to exceed 0.5 mg/kg/d
>14 years: Administer as in adults

Anticholinergic agents may antagonize effects of metoclopramide; opiate analgesics may increase toxicity in the CNS

Documented hypersensitivity; pheochromocytoma; GI hemorrhage, obstruction, or perforation; history of seizure disorders; coadministration of drugs likely to cause extrapyramidal symptoms

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Caution in renal impairment (decrease dose), hypertension, and depression

More on Superior Mesenteric Artery Syndrome

Overview: Superior Mesenteric Artery Syndrome
Differential Diagnoses & Workup: Superior Mesenteric Artery Syndrome
Treatment & Medication: Superior Mesenteric Artery Syndrome
Follow-up: Superior Mesenteric Artery Syndrome
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Gerasimidis T, George F. Superior Mesenteric Artery Syndrome. Wilkie Syndrome. Dig Surg. May 20 2009;26(3):213-214. [Medline].

  2. Merrett ND, Wilson RB, Cosman P, Biankin AV. Superior mesenteric artery syndrome: diagnosis and treatment strategies. J Gastrointest Surg. Feb 2009;13(2):287-92. [Medline].

  3. Kyslan K, Barla J, Kyslan K, Stanislayova M. [Superior mesenteric artery (SMAS/AMS) syndrome and its management]. Rozhl Chir. May 2008;87(5):255-8. [Medline].

  4. Ha CD, Alvear DT, Leber DC. Duodenal derotation as an effective treatment of superior mesenteric artery syndrome: a thirty-three year experience. Am Surg. Jul 2008;74(7):644-53. [Medline].

  5. Morris TC, Devitt PG, Thompson SK. Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome-How I Do It. J Gastrointest Surg. Apr 9 2009;[Medline].

  6. Jo JB, Song KY, Park CH. Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome: report of a case. Surg Laparosc Endosc Percutan Tech. Apr 2008;18(2):213-5. [Medline].

  7. Altiok H, Lubicky JP, DeWald CJ, Herman JE. The superior mesenteric artery syndrome in patients with spinal deformity. Spine. Oct 1 2005;30(19):2164-70. [Medline].

  8. Altman DH, Puranik SR. Superior mesenteric artery syndrome in children. Am J Roentgenol Radium Ther Nucl Med. May 1973;118(1):104-8. [Medline].

  9. Baltazar U, Dunn J, Floresguerra C. Superior mesenteric artery syndrome: an uncommon cause of intestinal obstruction. South Med J. Jun 2000;93(6):606-8. [Medline].

  10. Barnes JB, Lee M. Superior mesenteric artery syndrome in an intravenous drug abuser after rapid weight loss. South Med J. Mar 1996;89(3):331-4. [Medline].

  11. Crowther MAA, Webb PJ, Eyre-Brook IA. Superior mesenteric artery syndrome following surgery for scoliosis. Spine. 2002;27:E528-33.

  12. Hutchinson DT, Bassett GS. Superior mesenteric artery syndrome in pediatric orthopedic patients. Clin Orthop. Jan 1990;(250):250-7. [Medline].

  13. Massoud WZ. Laparoscopic management of superior mesenteric artery syndrome. Int Surg. Oct-Dec 1995;80(4):322-7. [Medline].

  14. Munns SW, Morrissy RT, Golladay ES. Hyperalimentation for superior mesenteric-artery (cast) syndrome following correction of spinal deformity. J Bone Joint Surg Am. Oct 1984;66(8):1175-7. [Medline].

  15. Ortiz C, Cleveland RH, Blickman JG. Familial superior mesenteric artery syndrome. Pediatr Radiol. 1990;20(8):588-9. [Medline].

  16. Raissi B, Taylor BM, Taves DH. Recurrent superior mesenteric artery (Wilkie's) syndrome: a case report. Can J Surg. Oct 1996;39(5):410-6. [Medline].

  17. Rokitansky C. Handbuch der Pathologischen Anotomie. Vienna: Branmiller and Siedel. 1842.

  18. Santer R, Young C, Rossi T. Computed tomography in superior mesenteric artery syndrome. Pediatr Radiol. 1991;21(2):154-5. [Medline].

  19. Shah MA, Albright MB, Vogt MT, Moreland MS. Superior mesenteric artery syndrome in scoliosis surgery: weight percentile for height as an indicator of risk. J Pediatr Orthop. Sep-Oct 2003;23(5):665-8. [Medline].

  20. Shapiro G, Green DW, Fatica NS, Boachie-Adjei O. Medical complications in scoliosis surgery. Curr Opin Pediatr. Feb 2001;13(1):36-41. [Medline].

  21. Shetty AK, Schmidt-Sommerfeld E, Haymon ML. Radiological case of the month. Superior mesenteric artery syndrome. Arch Pediatr Adolesc Med. Mar 1999;153(3):303-4. [Medline].

  22. Vitale MG, Higgs GB, Liebling MS, et al. Superior mesenteric artery syndrome after segmental instrumentation: a biomechanical analysis. Am J Orthop. Aug 1999;28(8):461-7. [Medline].

  23. Wilkie DPD. Chronic duodenal ileus. Am J Med Sci. 1927;173:643-9.

  24. Ylinen P, Kinnunen J, Hockerstedt K. Superior mesenteric artery syndrome. A follow-up study of 16 operated patients. J Clin Gastroenterol. Aug 1989;11(4):386-91. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

superior mesenteric artery syndrome, SMA syndrome, cast syndrome, Wilkie's syndrome, Wilkie syndrome, arteriomesenteric duodenal compression syndrome, chronic duodenal ileus, scoliosis, megaduodenum, small bowel obstruction, peptic ulcer disease, diagnosis, treatment

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Shervin Rabizadeh, MD, MBA, Pediatric Gastroenterologist, Cedars Sinai Medical Center; Instructor, Department of Pediatrics, University of California, Los Angeles, David Geffen School of Medicine
Shervin Rabizadeh, MD, MBA is a member of the following medical societies: American Academy of Pediatrics, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition
Disclosure: Nothing to disclose.

Medical Editor

Jorge H Vargas, MD, Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, David Geffen School of Medicine, University of California at Los Angeles; Consulting Physician, Department of Pediatrics, University of California at Los Angeles Health System
Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

B UK Li, MD, Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin
B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

RELATED MEDSCAPE ARTICLES
Articles
 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.