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Table of Contents
Abstract
Introduction
Case Report
Discussion
References

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Abstract

To begin with, it should be emphasized that the Superior mesenteric artery (SMA) syndrome is generally regarded as a rare, nevertheless, life-threatening gastrointestinal disorder featured by a compression of the third portion of the duodenum by the abdominal aorta and the overlying superior mesenteric artery. The normal angle between the abdominal aorta and Superior mesenteric artery is ranging between 38°-56°. The syndrome is caused by the angle ranging 6°-25°, which is caused by a lack of retroperitoneal fat. The aortomesenteric distance is 2-8 millimeters, while the norm is ranging between 10 and 20.

The symptoms of the syndrome, following Baltazar (2000) include:

“…early satiety, nausea, bilious vomiting of large quantities of partially undigested food, postprandial abdominal pain, which is caused by the duodenal compression and the compensatory reversed peristalsis, abdominal distention/distortion, eructation, external hypersensitivity or tenderness of the abdominal area, and severe malnutrition accompanying spontaneous wasting”.

The loss of weight then causes an increase in duodenal compression. Originally, the symptoms can be relieved when a patient is laid in the knee-to-chest position.

The paper aims to review and discuss the case study of a 30-years-old Asian American woman with Superior Mesenteric Artery Syndrome, aggravated by Bipolar Disorder, amphetamine use, and Attention-Deficit Hyperactivity Disorder. Originally, ADHD is regarded to be a pediatric syndrome, nevertheless, it is stated that children with this disorder continue experiencing it in adult age. The treatment, which was offered to the woman is represented and discussed.

As the original problem was regarded to be the prolonged use of Adderall, which is a combination of dextroamphetamine and amphetamine, and it is approved for the treatment of ADHD and Narcolepsy for children and adults. One of the consequences of Adderall use is loss of weight. Rapid weight loss is associated with the pathogenesis of SMAS caused by the decrease of mesenteric and retroperitoneal fat, resulting in mechanical compression of that portion of the duodenum that travels between the SMA and aorta by the short ligament of Treitz or by an unusually low origin of SMA in the route to the jejunum.

Introduction

Superior Mesenteric Artery Syndrome (SMAS) also known as Cast Syndrome, Mesenteric Root Syndrome, Wilke’s disease and is generally associated with rapid loss of weight. SMAS is caused by the loss of mesenteric and retroperitoneal fat pads causing compression of the third part of the duodenum between the superior mesenteric artery and aorta resulting in an acute angle between the SMA and aorta. SMAS is closely associated with conditions that cause significant weight loss, such as anorexia nervosa, malabsorption, increased catabolic states, cardiac cachexia, trauma, and malignancies. We report a case of a female with abdominal pain, vomiting, and weight loss who developed SMAS as a result of amphetamine use. To our knowledge, this association has not been reported previously.

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Case Report

A 30-years-old female with bipolar disorder, amphetamine use, and ADHD, taking Adderall, presented with abdominal pain, which lasted for five days. The pain was mostly concentrated in the right upper quadrant and epigastrium and described as sharp and constant. It is exacerbated by eating and associated with bilious vomiting. Moreover, it is featured with a decrease in appetite and a thirty-pound weight loss over one to two months.

Physical examination revealed a cachectic, young, Asian American female with a benign exam except for RUQ tenderness on an abdominal exam as well as pharyngeal erythema. ACT abdomen revealed that the stomach and duodenum were markedly dilated up to the third portion. an abrupt transition at the third part of the duodenum was observed, where it crosses the aorta. A paucity of intraperitoneal fat was noted. A nasogastric tube was placed. IV nutrition was started and her nausea was treated with antiemetic medication. An esophagogastroduodenoscopy performed on the second day of hospitalization revealed no abnormalities.

Aortegram AP and lateral, and SMA angiography were performed. These tests showed an acute angle between the SMA and the aorta. These arteries were patent. A markedly elongated gastroepiploic artery consistent with a dilated stomach was found. The patient’s nausea remained controlled, the NG tube was removed, and a clear liquid diet was started. Psychiatry was consulted for adjustment of her medications. She was discharged with conservative management and a goal of weight gain.

Discussion

Adderall is a combination of dextroamphetamine and amphetamine, and it is approved for the treatment of ADHD and Narcolepsy for children and adults. One of the consequences of Adderall use is loss of weight. Rapid weight loss is associated with the pathogenesis of SMAS caused by a decrease of mesenteric and retroperitoneal fat, resulting in mechanical compression of that portion of the duodenum that travels between the SMA and aorta by the short ligament of Treitz or by an unusually low origin of SMA in the route to the jejunum. Attention deficit hyperactivity disorder (ADHD) was regarded as a pediatric condition.

However, the available data suggest that between 30 and 70 percent of children with ADHD continue to manifest symptoms in adulthood. Patients with SMAS are usually young and suffer from nonspecific symptoms, such as nausea, vomiting, epigastric pain, postprandial discomfort, bloating, and weight loss. The symptoms usually occur after or are aggravated by eating. They are usually relieved by postural changes, such as turning to the left side, in a prone or knee-chest position. The diagnosis of SMAS is frequently a difficult one because the symptoms are so vague and is frequently a diagnosis of exclusion.

It is usually based on the radiologic findings of obstruction as well as decrease in angle and distance between SMA and aorta as well gastric and duodenal dilatation on CT or MRI. The gold standard for a definitive diagnosis is angiography. The regular aortomesenteric angle is 25 to 60 degrees and the SMA- aorta distance is 10-28 mm. In SMAS the angle has been reported to be 7-22 degrees and the distance was found to be 2-8 mm.

The goal of treatment of SMA syndrome involves weight gain to restore the aortomesenteric angle. The patient may be placed in a left lateral decubitus, knee-chest, or prone position to temporarily relieve the obstruction. A regime of small frequent feeds can be undertaken to increase caloric intake. Also, enteral, or parenteral nutrition can be considered. first involves gastric decompression to prevent complete duodenal obstruction. Patients must be given nutritional support to restore the retroperitoneal fat. It has been found that restoration of the angle alleviates symptoms in 62 to 66 percent of patients with SMA syndrome.

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Surgical intervention becomes necessary if conservative medical therapy fails. The most currently used method of surgical correction is dudoenojejunostomy. In our patient, the SMAS was caused by the rapid weight loss closely linked with the use of stimulants. Weight loss is a known side effect of stimulant use, which can lead to a pathophysiologic setting of malnutrition contributing to the development of Superior Mesenteric Artery Syndrome.

Abdominal pain, nausea, and vomiting as well as early satiety can further hinder malnutrition and accelerate the progression of SMAS. Our patient reported a 1–2-month duration of weight loss before rapidly deteriorating. After being discharged from the hospital the patient was encouraged to gradually gain weight and see a psychiatrist for re-evaluation of ADHD medication. 6 months after discharge, the patient has gained 18 pounds, currently not used Adderall, and reported complete resolution of symptoms without re-admission.

It has been estimated that about eight million adults have ADHD in the United States. There has been much debate over the overdiagnosis and treatment of ADHD. Stimulants remain to be the most widely used treatment for ADHD. College campuses known to be highly competitive or have a high rate of binge drinking had up to 25% of students who misused an ADHD medication within one year, a survey of students at 119 colleges across the country concluded.

Based on this information the true number of people that use amphetamines legally and illegally is variable and quite large which is why we believe that that it is important for physicians to remain alert to the possible association of stimulant use and SMAS. This association should be considered in patients that are currently being treated for ADHD as well as young, driven individuals in whom the abdominal symptoms are associated with a rapid weight loss of unknown etiology, especially when the symptoms are suggestive of small bowel obstruction.

References

Baltazar U, Dunn J, Floresguerra C, Schmidt L, Browder W (2000). “Superior mesenteric artery syndrome: an uncommon cause of intestinal obstruction”. South. Med. J. 93 (6): 606–8. PMID.

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