Food Insecurity Leading to Superior Mesenteric Artery Syndrome Managed Successfully with Endoscopic Gastrojejunostomy Stent

Background

Food insecurity is a condition in which individuals or households do not have adequate and reliable access to food due to insufficient resources, often leading to malnutrition. Although the prevalence of food insecurity in the United States has steadily decreased since 2011, it still affects approximately 10.5% of the population per the most recent data reported in 2020 by the United States Department of Agriculture. In isolation, these numbers are considerable but rise to new levels of concern when taken into context that the United States had the highest gross domestic product in the world in 2021 ($23 trillion) [1]. According to the United Nations International Children’s Emergency Fund (UNICEF) report on “The State of Food Security and Nutrition in the World,” 2.37 billion people in the world lacked access to adequate food in 2020. Moderate or severe global food insecurity rose from 22.6% to 26.6% between 2014 and 2019. The COVID-19 pandemic significantly impacted these numbers, resulting in a rise to 30.4% in the year 2020, with around 928 million people experiencing severe food insecurity. Major factors that threaten global food security include increased conflicts, climate variability, rising costs of nutritious food, and economic slumps; these challenges are amplified by poverty and inequality [2].

Numerous negative health outcomes are associated with food insecurity, including iron deficiency anemia, childhood asthma, depression, anxiety, poor oral health, peripheral arterial disease, and diabetes, to name a few [3–10]. In 2019, 29.9% of women aged 15 to 49 years worldwide were affected by anemia, a Sustainable Development Goal (SDG) indicator. In 2020, 149.2 million children under the age of 5 years had stunting, and 45.4 million were wasted [2].

In this report, we detail a rare adverse health outcome directly attributable to food insecurity: superior mesenteric artery (SMA) syndrome, and a novel treatment strategy: endoscopic gastrojejunostomy stent. SMA syndrome is a rare condition in which reduction in the angle formed by the proximal SMA and aorta, most commonly from decreased mesenteric fat in the setting of significant weight loss, leads to compression of the third portion of the duodenum and resulting bowel obstruction [11].

Case Report

A 33-year-old woman presented to the Emergency Department with a 1-year history of intermittent right upper quadrant abdominal pain, bloating, nausea, and nonvolitional bilious vomiting shortly after food consumption. Her medical history included end-stage renal disease secondary to focal segmental glomerulosclerosis, requiring outpatient hemodialysis 3 times weekly, hypertension, and gastrointestinal reflux.

For the preceding 2 years, she had been living with her step-father with extremely limited access to food, resulting in significant weight loss. Her chronic post-prandial symptoms began after reduction in her body mass.

On evaluation, she was afebrile, hypertensive (166/103 mmHg), severely underweight (body mass index 13.45 kg/m2), with otherwise normal vital signs. She was cachectic, with mid-epigastric tenderness to light palpation without abdominal distension, rebound, or guarding.

Laboratory test results demonstrated mild elevations in AST (72 U/L), ALT (97 U/L), total bilirubin (2.7 mg/dL), direct bilirubin (1.9 mg/dL), alkaline phosphate (347 U/L), and lipase (1030 U/L; reference range 12–53 U/L). Serum triglyceride levels, serum pregnancy test, complete blood count with differential, and the remaining comprehensive metabolic panel were otherwise unremarkable.

Cross-sectional imaging with an abdominal/pelvic computed tomography (CT) showed moderate gastric and proximal duodenal distention with a transition point at the third portion of the duodenum as it passed between the aorta and superior mesenteric artery (Figure 1), with narrowing of the aortomesenteric angle (Figure 2).

Taking into consideration her longstanding postprandial symptoms preceded by significant weight loss, as well as her cross-sectional imaging findings, SMA syndrome was suspected. She was admitted to the hospital for symptom management, fluid resuscitation, and bowel rest. Within 24 h, her acute symptoms resolved, and her laboratory values normalized.

She was subsequently seen in consultation by General Surgery and Gastrointestinal Medicine teams, with initial plans for weight gain through per oral (p.o.) nutritional optimization with full liquid/soft diet and nutritional supplements. Although able to tolerate small amounts of food with each meal, she had recurrence of her symptoms with larger meals.

She underwent esophagogastroduodenoscopy (EGD), which demonstrated esophagitis, gastritis, a small hiatal hernia, and tight angulation in the third portion of the duodenum, with inability to advance the endoscope (Figure 3); SMA syndrome was formally diagnosed. It was recommended that the patient undergo placement of a gastrojejunostomy feeding tube for initiation of enteral tube feeds distal to the duodenal obstruction with gastric venting as needed. The patient preferred to improve her nutrition exclusively by p.o. intake, however. She underwent placement of an endoscopic gastrojejunostomy stent to bypass the duodenal obstruction (Figure 4). Twenty-four hours after gastrojejunal stent placement, the patient consumed only soft and moist foods, then was advanced to regular consistency thereafter. A dietician evaluated her nutritional needs and determined that she would require a minimum daily energy intake of 1120–1280 kcals and a minimum daily protein intake of 38–48 g. After demonstrating the ability to consistently tolerate a regular diet, she was discharged home with plans for ongoing close outpatient follow-up. Ideally, with gradual weight gain, she will redevelop increased mesenteric fat, thereby overcoming the occlusive physiology of SMA syndrome. In the future, if the obstruction resolves both clinically and radiographically after appropriate weight gain, the stent could be removed. If, however, she has ongoing symptoms despite appropriate weight gain, she may require permanent surgical bypass.

Given the concern for potential ongoing food insecurity, a social worker performed a comprehensive assessment of her current living circumstances, activities of daily living, means of transportation, and finances. Through Adult Protective Services, the patient was assigned an outpatient social worker to help ensure her access to food and safety after discharge from the hospital.

Discussion

SMA syndrome is a rare condition in which a reduction in the angle formed by the proximal SMA and aorta (normally between 38° and 65°) leads to compression of the third portion of the duodenum with proximal bowel obstruction [11]. Literature detailing this syndrome has been limited to case reports and small case series since it was first described by Rokitasnky in 1861 [12].

Reduction in the aorto-SMA angle is often the result of 1 of 2 processes: (1) extrinsic compression following surgery (often to correct the spine); and (2) significant weight loss [13]. In the latter circumstance, reduced mesenteric fat leads to a decrease in the aorto-SMA angle, with resulting compression of the duodenum. Described etiologies of weight loss leading to SMA syndrome include malabsorption, cancer, acquired immunodeficiency syndrome, burns, eating disorders, drug abuse, and surgery (eg, bariatric surgery, abdominal trauma) [14]. Unique to this case, there have been no published reports directly linking weight loss from food insecurity to the development of this condition; this adds to the growing list of negative health outcomes associated with food insecurity.

The rapid improvement in this patient’s acute cholestatic lab values in the first 24 hours without intervention supported the suspicion that this represented transient biliary stasis (eg, passage of biliary stone or sludge, duodenal compression by the SMA). Regarding the latter mechanism, SMA syndrome-associated acute pancreatitis has been reported in the literature, albeit rarely [15–22]. The most well-accepted proposed pathophysiologic mechanism is that duodenal compression by the SMA causes secondary post-papillary syndrome and retrograde reflux of bile into the pancreatic duct, resulting in inflammation [18]. At least 1 previous case noted improvement in a patient’s symptoms and serum amylase level after decompression of the distended proximal bowel, supporting the idea that increased intraluminal pressure in the duodenum can lead to high pancreatic duct pressures [22].

The most common symptoms of SMA syndrome include nausea, epigastric pain, vomiting, and weight loss [23]. Patients can also experience symptoms of severe gastrointestinal reflux secondary to chronic obstruction. Once the condition is established, these symptoms contribute to the inability to eat enough to regain weight, resulting in a vicious cycle of clinical deterioration.

Diagnosis is often established by CT or magnetic resonance imaging (MRI) showing gastric distension, dilation of the proximal duodenum, reduced aortomesenteric angle, and a transition point at the third portion of the duodenum. Upper gastrointestinal series can also demonstrate a dilated proximal duodenum, with inability of contrast to pass through the third portion of the duodenum.

Initial treatment is conservative, attempting p.o. intake with dietary modifications (full liquids, small/frequent meals, oral supplements). If unable to achieve adequate nutrition, initiation of total parenteral nutrition or placement of a gastrojejunostomy feeding tube or stent can be warranted. Once a means of nutritional intake is established, patients should be monitored closely for the development of refeeding syndrome. With adequate weight gain and development of increased mesenteric fat, SMA syndrome can resolve without surgical intervention. However, some patients may ultimately require long-term endoscopic gastrojejunostomy versus surgical gastrojejunostomy or duodenojejunostomy to permanently bypass the obstructed duodenum [24, 25]. Another surgical treatment option that has shown success is division of the ligament of Treitz and full mobilization of the duodenum away from the aorta [26]. In the present case, the patient underwent a relatively novel treatment approach, with the endoscopic placement of a gastrojejunostomy stent. This technique has been shown safe and effective for treatment of both benign and malignant causes of gastric outlet obstruction [27,28]. Only recently has this procedure been employed as a management strategy for SMA syndrome, with only a few published cases available in the literature [29–33]. The success of the procedure in our patient adds to the body of evidence supporting its efficacy and safety profile for this patient population.

Conclusions

Food insecurity remains a wide-ranging public health issue that can have direct impact on the health outcomes of individuals. We describe SMA syndrome as a rare adverse health outcome in a food insecure individual, demonstrating the need for a high index of suspicion in patients with limited resources who present with suggestive symptoms. This case also highlights endoscopic placement of a gastrojejunostomy stent as an emerging alternative to surgical interventions for the treatment of SMA syndrome.