Case in Point Winners

We selected this case because of its unique presentation and associated findings. The patient’s medical managing team was surprised when we communicated to them the finding of suspected gastric outlet obstruction on abdominal radiograph and recommended placement of an enteric tube with order for immediate cross-sectional imaging. They told us that the working diagnosis was constipation and were planning to treat it conservatively with enema. Follow-up computed tomography (CT) confirmed the upper gastrointestinal (GI) obstruction and revealed the underlying cause to be superior mesenteric artery (SMA) syndrome. The team was then able to elicit a history of significant rapid weight loss from the mother. 

Reading plain radiographs is an art that needs to be mastered by all radiologists. New trainees should be aware of the subtle, but information-laden clues to diagnosis that can show up on plain films and direct next steps of management.      

We learned that prior cases have been published on the accepted normal aortomesenteric angle and distance along with the range of these values that are diagnostic for SMA syndrome. Also, coexistence of SMA and nutcracker syndrome is rare even though they share similar pathophysiology.   

We were excited when our Attending, Dr. Hammill, agreed with our diagnosis. However, we were confused with the liver and splenic ischemic foci apparent on CT as this is not a phenomenon ever described to be associated with SMA syndrome. Dr. Hammill directed our attention to the compression of the retroperitoneal vascular structures including branches of the celiac artery by the markedly distended stomach.    

Case in Point is a valuable resource that enriches our residency education because we know we will not be directly exposed to every diagnosis during training. When we can review a variety of cases shared by others on the Case in Point platform, we are more confident that we will recognize them when they come up in the future.  

It was thrilling to see on follow-up imaging that the ischemic foci on the liver and spleen resolved after gastric decompression. It was also comforting that the patient could achieve relief with conservative management of refeeding and weight gain. 

Hadassah Stein, MD
PGY-1, Intern Year Radiology Resident
Internal Medicine
Mather Hospital at Northwell
Port Jefferson, NY

Temitope Soyemi, MBBS
PGY-5, Radiology Resident
Department of Radiology
SUNY Downstate
Brooklyn, NY

Patrick Hammill, MD
Diagnostic Radiologist
Department of Radiology, Diagnostic Imaging
Kings County Hospital Center
Brooklyn, NY