Understanding the diagnosis of superior mesenteric artery syndrome: analysis of the location of duodenal impression on upper gastrointestinal studies

• Published in: Pediatric radiology Vol. 53; no. 13; pp. 2633 - 2641
• Main Authors: Caterine, Scott, Patil, Nikhil S., Takrouri, Heba, Issenman, Robert M., Stein, Nina R., Donnellan, John, Yikilmaz, Ali
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01.12.2023; Springer Nature B.V
• Subjects: Abdomen; Aorta; Child; Compression; Coronary vessels; Diagnosis; Duodenum; Duodenum - diagnostic imaging; Female; Humans; Imaging; Infant; Male; Medicine; Medicine & Public Health; Mesenteric Artery, Superior; Neuroradiology; Nuclear Medicine; Oncology; Original Article; Patients; Pediatrics; Radiology; Retrospective Studies; Small intestine; Superior Mesenteric Artery Syndrome - diagnostic imaging; Superior Mesenteric Artery Syndrome - etiology; Ultrasound; Vertebrae; Superior mesenteric artery syndrome; Upper gastrointestinal series; Fluoroscopy; Children; Duodenum; Duodenal obstruction
• DOI: 10.1007/s00247-023-05782-8
• ISSN: 1432-1998; 0301-0449

Background Upper gastrointestinal (GI) contrast studies are frequently requested to aid superior mesenteric artery syndrome diagnosis, a rare entity. Compression of the third duodenal part is expected to be mid-to-left of the midline where the superior mesenteric artery arises from the aorta; however, a duodenal impression to the right of the midline due to normal anatomic impression by the inferior vena cava (IVC) is often encountered and frequently misdiagnosed. Objective The purpose of this study was to determine the frequencies of (1) normal right-of-midline duodenal impressions and (2) mid-to-left of midline compressions in upper GI studies in a tertiary pediatric referral center. Materials and methods All upper GI studies performed at our institution over 2 years were retrospectively evaluated to determine whether the duodenum had vertical duodenal impression to the right of the vertebral midline, mid-to-left of the vertebral midline, or no identifiable duodenal impression at all. Results In total, 538 upper GI studies were included in this analysis. A total of 275 male and 247 female patients between 0 and 17 years of age (median: 6 years, range: 1 month-17 years) were included. Of 538 total upper GI studies, there were 240 studies (44.6%) with a right-of-midline impression. There were only 10 studies (1.9%) with a mid-to-left of midline compression, and 9/10 also showed a concurrent right-sided impression sign. Conclusion Right-of-midline duodenal impression is a normal anatomic finding caused by the IVC and should not be confused with superior mesenteric artery syndrome. In the presence of an appropriate clinical context, proximal duodenal dilation, “to-and-fro” motion of contrast, and duodenal impression at mid-to-left of midline, a diagnosis of superior mesenteric artery syndrome should be considered. Graphical Abstract