An unusual cause of vomiting in a young female

Clinical scenario:
   A 22-year-old female presented with a history of recurrent vomiting of 3days duration. She denied a history of recent weight loss, anorexia, and fever.
On examination, the patient was thin but had no pallor, jaundice or lymphadenopathy.
The examination of the abdomen revealed a scaphoid soft abdomen with no organomegaly. The other systemic examination was unremarkable.
Investigations : 
     Her hemogram and tests on liver and kidney functions were normal. Keeping in view her recurrent vomiting an 
UGI Endoscopy was carried out which revealed normal esophagus, normal stomach but the second part of duodenum was full of bile which was sucked out and the scope was negotiated beyond. Fig1 
An impression of high gut obstruction was made and the patient was subjected to CT abdomen which showed third part of duodenum was compressed by the superior mesenteric artery and distal part was collapsed. Fig2 
An impression of Superior mesenteric artery syndrome was made. 
The patient was managed with IV fluids and is being followed up. 

Fig 1 EGD showing normal stomach with lot of bile present in D2 

Fig 2  CT scan abdomen  SMA syndrome.

Superior mesenteric artery syndrome first described in 1861 by Von Rokitanskyis. 

It is caused by compression of third part of the duodenum by the superior mesenteric artery.

The superior mesenteric artery usually forms an angle of approximately 45° (range, 38-56°) with the abdominal aorta, and the third part of the duodenum crosses caudal to the origin of the superior mesenteric artery, coursing between the superior mesenteric artery and aorta. 

Any factor that sharply narrows the aortomesenteric angle to approximately 6-25° can cause entrapment and compression of the third part of the duodenum as it passes between the superior mesenteric artery and aorta, resulting in superior mesenteric artery syndrome. Sudden weight loss leading to loss of fat can cause this syndrome.

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This case was contributed by 
Dr. Hakim Shafi 
MD.DM(Gastroenterology)
Senior Consultant Gastroenterologist 
District Hospital Anantnag Kashmir 
Directorate of Health services Kashmir.