Introduction: Superior mesenteric artery (SMA) syndrome is a rare and unusual acquired cause of functional duodenal obstruction whose diagnosis can be easily missed without knowledge of this condition. Case Presentation: We report a case of a 27-year-old female, presenting with post-prandial vomiting, early satiety, bloatedness and weight loss for about 10 months. Vital signs were stable. She was grossly underweight with a BMI of 11.72 kg/m2 (height=1.6m, weight=30kg). Physical examination was unremarkable. Gastrointestinal series revealed a narrowing in the third portion of the duodenum likely secondary to extrinsic compression. Contrast-enhanced CT scan of the whole abdomen was performed with 3D reconstruction. There were no definite signs of gastrointestinal obstruction. However, a narrow/acute aorto-mesenteric angle of 13 degrees compressing the third part of the duodenum was noted. Superior mesenteric syndrome was considered, prompting further work-up. Primary hyperthyroidism was the root cause of the patient’s weight loss that lead to this condition. Patient was given nutritional support, parenterally and enterally. She was discharged improved after oral feeding was tolerated and patient started to gain weight. Discussion: Superior mesenteric artery (SMA) syndrome is an uncommon medical condition brought about by a decrease in the aortomesenteric angle from the usual 45o to less than 15o resulting in vascular compression of the third part of the duodenum leading to gastrointestinal obstruction. A high index of suspicion is needed to prevent the diagnosis from being missed which may in turn lead to unnecessary testing and treatment. If recognized early, the condition may be managed conservatively. Surgical management is only required when conservative methods fail. Conclusion Early recognition and a thorough evaluation is therefore imperative so conservative measures can be maximized at the outset.
Superior Mesenteric Artery Syndrome

Introduction: Melioidosis among Filipinos may be underreported. The causative agent, Burkholderia pseudomallei, thrives in soil and water in tropical regions. Because our country thrives on agriculture as a source of livelihood, occupational exposure through farming needs to be recognized. Case Presentation: We report a case of a 40-year-old male complaining of intermittent fever, progressive weight loss and jaundice for three weeks prompting consult. Whole abdominal ultrasound showed presence of a hepatic mass. Further evaluation using CT scan of the whole abdomen with contrast revealed multiple cystic hepatic nodules with wall/septal enhancement. He was admitted and was initially managed as sepsis secondary to a complicated intra-abdominal infection (liver abscess, pyogenic or amebic). Ciprofloxacin and metronidazole were started. Aspiration of the hepatic abscess showed many pus cells. Culture of the aspirate grew Burkholderia pseudomallei, sensitive to ceftazidime. Antibiotics were shifted accordingly. Defervescence ensued. Patient was discharged improved after two weeks of ceftazidime wo grams every eight hours given intravenously followed by a three-month oral course of cotrimoxazole 160mg/800mg tablet, two tablets every 12 hours and doxycycline 150mg capsule every 12 hours. On follow-up after three months, he had no recurrence of symptoms and was able to resume his usual work. Discussion: Melioidosis is a disease of humans and animals that is geographically restricted to tropical countries since the organism thrives in soil and water. Symptom onset may be delayed due to the ability of the organism to produce latent infection. Isolation of B. pseudomallei from clinical specimens sent for culture and sensitivity testing is the diagnostic gold standard. Conclusion Melioidosis may present as an intraabdominal infection. A high clinical index of suspicion among those with occupational exposure to contaminated soil and water is important to promptly recognize and treat this infection.
Burkholderia pseudomallei