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Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 2339603210.5144/0256-4947.2012.659asm-6-659What's Your Diagnosis?An uncommon cause of duodenal obstruction Khalid Saifullah Khalid Mohd Ahmad Ibne Zaheer Samreen Jain Amit From the Department of Radiodiagnosis, Jawaharial Nehru Medical College & Hospital, AMU, Aligarh, IndiaCorrespondence: Dr. Saifullah Khalid, Radiodiagnosis, Jawaharial Nehru Medical College. House No.386-A, Street No.1 Iqra Colony Aligarh UP 202002 India, T: 09897218098, saif2k2@gmail.comNov-Dec 2012 32 6 659 659 Copyright © 2012, Annals of Saudi Medicine2012This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
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A 30-year-old female patient presented to the gastroenterology outpatient department with complaints of anorexia, weight loss and vomiting off and on for the previous 6 months. There was no history of jaundice or diabetes. The patient had mild pallor but her vital signs were within normal ranges. Ultrasound of the abdomen revealed gross distension of the stomach and the proximal part of the duodenum. A barium meal was followed by contrast enhanced computed tomography.

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Figure 1 Barium meal shows dilated stomach and duodenum with sudden narrowing of the third part of the duodenum (arrow). Delayed image (1b) shows minimal distal passage of contrast but persistent narrowing with proximal dilatation.

Figure 2 Contrast-enhanced computed tomography of the abdomen shows dilated stomach, first and second part of duodenum with transition point in the third part of duodenum. CT scan also rules out any luminal or intrinsic cause of compression. Sagittal reconstruction (2d) shows decreased aortomesenteric angle to 22°.

Ann Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre asm-6-659aWhat's Your Diagnosis?Answer: Wilkie syndrome Khalid Saifullah Khalid Mohd Ahmad Ibne Zaheer Samreen Jain Amit From the Department of Radiodiagnosis, Jawaharial Nehru Medical College & Hospital, AMU, Aligarh, IndiaCorrespondence: Dr. Saifullah Khalid, Radiodiagnosis, Jawaharial Nehru Medical College, House No.386-A, Street No.1 Iqra Colony Aligarh UP 202002 India, T: 09897218098, saif2k2@gmail.comNov-Dec 2012 32 6 Copyright © 2012, Annals of Saudi Medicine2012This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.Wilkie syndrome (or superior mesenteric artery syndrome), also known by other names such as aortomesenteric duodenal compression, Cast syndrome and chronic duodenal ileus first observed in 1842 by Rokitansky, but first reported by Wilkie.1

Wilkie syndrome is a rare condition that results from vascular compression of the third part of the duodenum, in the angle between the descending aorta and the origin of the superior mesenteric artery (SMA). There is a cushion of fat and lymphatics around the SMA and due to rapid weight loss, the protective action of fat is lost. On sagittal section of CT abdomen, the normal aortomesenteric angle ranges from 25° to 60° and normal aortomesenteric distance ranges from 10 to 28 mm. However, in Wilkie syndrome both are reduced.2,3

Management consists of conservative maneuvers and surgery. Conservative measures include nasogastric decompression and frequent small meals in the left lateral or prone position (posturing maneuvers). Motility agents (eg, metoclopramide) may be helpful in some patients. Surgical options are considered when conservative maneuvers fail and include duodenojejunostomy (most common), Strong operation (mobilizing duodenum by dividing the ligament of Treitz) and transposition of the third part of duodenum anterior to the superior mesenteric vessels.4,5