Abstract Background Superior mesenteric artery syndrome is a rare form of duodenal obstruction that usually requires nonoperative management. While individual complications such as acute pancreatitis, portal venous gas, and gastric emphysema have been reported, the simultaneous occurrence of this triad in a single patient with superior mesenteric artery syndrome has never been documented. This case is novel as it highlights the successful nonoperative management of superior mesenteric artery syndrome despite the presence of these severe, potentially life-threatening complications. Case presentation A 26-year-old Asian male with a constitutional low body mass index of 14.53 kg/m 2 presented with abrupt epigastric pain and bilious vomiting. Investigations revealed a diagnosis of superior mesenteric artery syndrome complicated by acute pancreatitis, portal venous gas, and gastric emphysema. The patient was treated nonoperatively with intensive care support, including nasogastric decompression and total parenteral nutrition. The interventions led to a significant reduction in gastric output, resolution of acute kidney injury and pain, and subsequent removal of the nasogastric tube. The patient was discharged well and showed no signs of obstruction at the 9-month follow-up, having gained weight. Conclusions This case demonstrates that the presence of portal venous gas and gastric emphysema in superior mesenteric artery syndrome, which typically raises suspicion for gastrointestinal necrosis, can be successfully managed conservatively if clinical signs of perforation or sepsis are absent. Clinicians should maintain a high index of suspicion for the complex presentations of superior mesenteric artery syndrome and prioritize aggressive nonoperative nutritional support, as it can resolve obstruction and preclude the need for surgery even in the setting of severe multi-systemic complications.
Punyanirun et al. (Wed,) studied this question.