Critical Care: Student/Resident Case Report Poster - Critical Care II |

Wilkie’s Syndrome Causing Acute Gastric Necrosis FREE TO VIEW

Nisha Ajit, MBBS; Kovid Trivedi, MBBS; Robert Walter, MD
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Louisiana State University of Health Sciences, Shreveport, LA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):407A. doi:10.1016/j.chest.2016.08.420
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Superior mesenteric artery (SMA) syndrome or Wilkie’s syndrome is compression of the third part of the duodenum between the SMA & abdominal aorta. This compression can lead to acute gastric dilation and necrosis of the stomach. SMA syndrome leading to acute gastric dilation is rare and necrosis of the stomach; an organ with extensive collateral blood supply can be fatal.

CASE PRESENTATION: A 26-year-old male with a history of type I diabetes presented with vomiting and abdominal pain of 1 day. Exam was remarkable for BP of 93/60 mm Hg & HR of 106. Patient was cachectic & in distress, abdomen was distended with diffuse tenderness. Labs revealed Hb of 8, leucocytosis of 13000 and lactate of 3.6. IV fluid bolus & antibiotics were started. 6 hours later he had emesis of black fluid with development of shock requiring vasopressors, intubation for acute respiratory failure and intensive care. Abdominal X-ray showed a giant lucency, thought to be the distended stomach. NG tube inserted returned 2.4 liters of black fluid. CT abdomen showed a distended gastric & esophageal lumen with a transition point between the 2nd and 3rd part of duodenum. EGD showed deep ulcerations over the stomach and eschar formation. Upper GI series confirmed SMA syndrome. As patient continued to be in septic shock ,surgery was deferred. Explorative laparotomy done on Day 9 of admission, ended in total gastrectomy and esophago-jejunostomy & a feeding jejunostomy. Post procedure patient had a prolonged recovery.

DISCUSSION: SMA syndrome occurs in hyper catabolic states such as malignancy, burns and anorexia nervosa. Acute gastric dilation results in sudden increase in intraluminal gastric pressure and gastric venous insufficiency causing gastric necrosis.1 SMA syndrome is initially treated conservatively with gastric decompression, correction of electrolytes & nutritional support.2 Surgical intervention is needed if there is no resolution or if signs of sepsis develop. In our patient the diagnosis and later the surgical intervention was delayed resulting in increased morbidity.

CONCLUSIONS: As the presentation is often non-specific for the above-described entities a high index of suspicion & early abdominal imaging with a KUB, followed by a CT abdomen, if required is the key to diagnosis. Early diagnosis is imperative to prevent onset of necrosis & once identified, early surgical intervention can salvage viable bowel.

Reference #1: Steen S, Lamont J, Petrey L. Acute gastric dilation and ischemia secondary to small bowel obstruction. Proc (Bayl Univ Med Cent). 2008 Jan;21(1):15-7.

Reference #2: Merrett ND, Wilson RB, Cosman P, Biankin A V. Superior Mesenteric Artery Syndrome: Diagnosis and Treatment Strategies. J Gastrointest Surg. 2009 Feb 23;13(2):287-92.

DISCLOSURE: The following authors have nothing to disclose: Nisha Ajit, Kovid Trivedi, Robert Walter

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