Superior mesenteric artery syndrome in a patient with HIV

A man of 27 with established AIDS was referred with a diagnosis of cerebral toxoplasmosis and clinical features of high gastrointestinal obstruction. He had been vomiting profusely for six weeks and was unable to retain anything orally. He now weighed just 30 kg. Inability to retain his antiviral medication had led to worsening immunosuppression, and severe oral and oesophageal candidiasis prevented him swallowing his own saliva. The cerebral toxoplasmosis had resulted in mild left sided hemiparesis. On examination of the abdomen there was epigastric fullness with a positive succussion splash. Ultrasound showed the stomach to be massively distended, and CT demonstrated obstruction of the third part of the duodenum by extrinsic compression. A narrow aorto-mesenteric angle in the sagittal section was highly suggestive of superior mesenteric artery (SMA) syndrome (Figure 1) and hypotonic duodenography showed typical cut-off at the third part of the duodenum. An attempt was made at conservative management, initially with total parenteral nutrition and later with nasogastric feeding. However, weight loss continued and the nasogastric aspirate remained greater than 1L/day. Enteral access was necessary for administration of his antiviral and antitoxoplasmosis medication. Surgical intervention was therefore required. The options included a feeding jejunostomy alone (to improve the patient’s nutritional and immune status) or a definitive procedure for SMA syndrome. The latter was chosen. Intraoperative findings confirmed the presence of SMA syndrome. The stomach and proximal duodenum were distended and there was visible compression of the third part of the duodenum, 350 J O U R N A L O F T H E R O Y A L S O C I E T Y O F M E D I C I N E V o l u m e 9 6 J u l y 2 0 0 3