Vomiting Associated with Rapid Weight Loss

An 82-year-old woman with advanced Alzheimer’s disease presented to the gastroenterology department with vomiting. At presentation, her vital signs were normal. However, her upper abdomen was distended. Fifteen months previously, she underwent surgery for right femoral neck fracture. Although the postoperative course was good, her daily living activities decreased. In addition, with a height of 158.0 cm, she experienced severe weight loss of 19.2 kg in the last 15 months (from 54.2 kg to 35.0 kg). Abdominal computed tomography (CT) showed a dilated stomach and duodenum, and a compression of the third part of duodenum in angle between the aorta and the superior mesenteric artery (SMA) (Fig. 1A). After decompression using endoscopy, esophagogastroduodenoscopy confirmed the extramural compression (Fig. 1B). A diagnosis of SMA syndrome (SMAS) was made. Since no aggressive treatment was desired, palliative care was performed.

FIG. 1. (A) Abdominal computed tomography showing a dilated stomach (white asterisks) and duodenum (yellow asterisk), and a compression of the third part of duodenum in angle between the aorta (yellow arrow) and the superior mesenteric artery (yellow arrowhead). (B) Esophagogastroduodenoscopy confirming the extramural compression (black arrows).

SMAS is a rare syndrome characterized by symptoms resulting from vascular compression or an obstruction of the third part of duodenum in angle between the aorta and the SMA.1 Clinical symptoms include nausea, vomiting, post-prandial epigastric pain, weight loss, and anorexia.1 Rapid weight loss can lead to a depletion of mesenteric and retroperitoneal fat and subsequent decrease of the aortomesenteric distance.1 An aortomesenteric angle of <22-25 degrees and a distance of <8 millimeters have been reported as diagnostic cut-off values.1 In the present case, the aortomesenteric angle was estimated to be approximately 21 degrees with an aortomesenteric distance of 3 millimeters as determined by CT.

In absence of displacement by an abdominal mass, an aneurysm, or other pathology requiring immediate surgical intervention, initial treatment is conservative: nasogastric tube placement for duodenal and gastric decompression, mobilization into the prone or left lateral decubitus position to ease pressure on duodenum and reduce epigastric pain, correction of the fluid and electrolyte balance, and enteral jejunal tube feeding.1 Surgery is indicated in symptomatic patients when conservative treatment fails.1