Clinical Image-Superior Mesenteric Vein Syndrome

A 59 year old male with history of cerebral palsy presented with a 5-day history of abdominal pain, distension, nausea, and vomiting. He underwent a CT scan without a distinct transition point causing bowel obstruction.  The patient was admitted and underwent an esophagogastroduodenoscopy (EGD), which confirmed extrinsic compression of the duodenum. Upon further review of the CT scan, it was noted that there was mild compression at the third and fourth portions of the duodenum between vascular structures, and not the expected structures of the aorta and superior mesenteric artery.  The patient was taken to the operating room and underwent diagnostic laparoscopy with laparoscopic mobilization of the right colon and the entire duodenum to the ligament of treitz. Intra-operatively, the patient was found to have extrinsic compression of the duodenum between the inferior vena cava (IVC) and the superior mesenteric vein (SMV). The SMV was dissected off the anterior duodenum, creating space between these two structures and relieving the extrinsic compression. EGD was performed at the end of the case and the duodenum was successfully traversed endoscopically.