SMA Syndrome: Symptoms, Diagnosis, and Treatment Options

Suspected SMA syndrome?

Dear Dr.
Chen,
I previously consulted you about some abdominal issues.
I have been experiencing persistent abdominal discomfort (bloating and pain) for almost a year now.
Despite taking medication and actively seeking medical attention, there has been little improvement.
Due to work commitments, I have been visiting a regional hospital in Miaoli, where I was told that I only have functional dyspepsia.
However, I have lost 6 kilograms, and I can feel a palpable mass in my abdomen.

I brought the CT scan I had done at the regional hospital in September to a doctor at China Medical University, who initially suspected SMA syndrome, as my BMI is approximately 18.8, and the CT showed a narrow distance between the SMA and the aorta (the relevant CT images can be found at this link: https://drive.google.com/drive/folders/0BwKmzeu3uxdpYnRsYllIOWhCb2s?usp=sharing).
The doctor then arranged for a small bowel barium X-ray, which indicated narrowing or compression at the third part of the duodenum.
This further convinced the doctor of SMA syndrome (the small bowel imaging from December 22 can be found here: https://drive.google.com/drive/folders/0BwKmzeu3uxdpYWJSMkRndkhfQzQ?usp=sharing).

In January, I underwent an upper gastrointestinal endoscopy, but it could only reach the second part of the duodenum.
The doctor could barely see signs of compression when looking towards the third part.
The doctor suggested that if I wanted further examination, I would need to pay out of pocket for a small bowel endoscopy or a CT scan, which would cost around 50,000 NTD.
Currently, the conservative treatment involves eating smaller, more frequent meals to gain weight, but I am still feeling quite uncomfortable.

I returned to the regional hospital near my home in Miaoli with the small bowel X-ray results, but the doctor there said that the small bowel X-ray appeared normal and that the third part of the duodenum did not seem compressed.
Upon reviewing the CT report from their radiologist, it also stated that there were no abnormalities.
I plan to continue monitoring my condition, but I would like to ask you, Dr.
Chen:
1.
Based on these imaging results and symptoms, do you think the likelihood of SMA syndrome is high?
2.
Can MRI be used to assess the angle between the SMA and the aorta? Can I apply for health insurance coverage for my symptoms?
3.
The small bowel endoscopy costs 50,000 NTD, but I am only a few centimeters away from reaching the third part.
Is there a longer endoscope available? (The last endoscope used was 110 cm long.)
4.
I also underwent left-sided varicocele ligation surgery on October 2 due to varicocele disease.
Could this be related to compression of the left renal vein by the SMA, causing nutcracker syndrome?
Thank you very much for taking the time to review my questions.
I hope to gain some insights from your expertise!

A-Lin, 20~29 year old female. Ask Date: 2017/01/12

Dr. Chen Jiaming reply Surgery

I apologize for the delay in responding to your inquiry due to issues with our information system.
Firstly, I do not believe that your original symptoms align with the typical clinical presentation of Superior Mesenteric Artery (SMA) syndrome.
Of course, as your condition worsens and you experience weight loss, your imaging may resemble SMA syndrome.
However, that is a consequence, not a cause.
Excessive medical information can be overwhelming, and I cannot pinpoint the exact issue with your condition in one statement.
I can only tell you that SMA syndrome is not a favorable direction to consider, so your various questions regarding it do not need to be taken into account.

Reply Date: 2017/01/12

More Info

SMA syndrome, or Superior Mesenteric Artery syndrome, is a rare condition that occurs when the duodenum is compressed between the aorta and the superior mesenteric artery (SMA). This compression can lead to gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and weight loss. Given your symptoms of abdominal discomfort, weight loss, and the findings from various imaging studies, it is understandable that there is concern regarding the possibility of SMA syndrome.

1. Probability of SMA Syndrome: Based on the information provided, the probability of SMA syndrome cannot be definitively concluded without further investigation. While your BMI is on the lower side, which can be a risk factor for SMA syndrome, the imaging results have been inconsistent. The CT scan indicated a narrow angle between the SMA and the aorta, but the subsequent small bowel X-ray and the local hospital's review of the CT did not show any significant abnormalities. This discrepancy suggests that while SMA syndrome is a possibility, it may not be the most likely diagnosis. It is essential to consider other potential causes of your symptoms, such as functional dyspepsia or other gastrointestinal disorders.

2. MRI and Angiography: Magnetic Resonance Imaging (MRI) combined with Magnetic Resonance Angiography (MRA) can be used to assess the angle between the SMA and the aorta. This method is particularly useful for patients who have had allergic reactions to contrast agents used in CT scans. MRI can provide detailed images of soft tissues and blood vessels, which may help clarify the situation regarding the SMA and its relationship with the aorta.

3. Health Insurance Coverage: Regarding whether your symptoms can be covered by health insurance, this typically depends on the specific policies of your insurance provider and the medical necessity of the tests. If your physician believes that further imaging is warranted to rule out SMA syndrome or other conditions, they may be able to provide documentation to support your claim for coverage.

4. Length of Endoscope: The length of the endoscope used during your previous examination (110 cm) is standard for upper gastrointestinal endoscopy. However, if deeper access is needed, there are longer endoscopes available, but they may not be commonly used in all facilities. Discussing this with your gastroenterologist may provide options for further investigation.

5. Nutcracker Syndrome: Your history of left-sided varicocele and the potential for nutcracker syndrome, which occurs when the left renal vein is compressed between the SMA and the aorta, is another important consideration. This condition can lead to symptoms such as flank pain, hematuria, and varicocele. It is plausible that the SMA could be contributing to the compression of the left renal vein, especially if you have a history of vascular issues.

In conclusion, while SMA syndrome is a consideration given your symptoms and imaging findings, the conflicting results from different medical facilities suggest that further investigation is necessary. Consulting with a specialist in vascular surgery or gastroenterology may provide additional insights and help determine the best course of action for diagnosis and treatment. It is crucial to continue monitoring your symptoms and seek further evaluation if they persist or worsen.

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