Background

This is a case of a seventeen year old newly quadriplegic male with history of significant weight loss, who presented with epigastric pain. Imaging was significant for a severely dilated stomach and duodenum, with an abrupt transition point in the third portion of the duodenum where the superior mesenteric artery crosses, suspicious for superior mesenteric artery syndrome. Gastric decompression by nasogastric tube was recommended, but the patient refused. He subsequently became hemodynamically unstable and was taken for exploratory laparotomy, where an anterior proximal gastric perforation was noted and closed with a wedge resection. Patient returned to the operating room multiple times during his hospital stay in which he was diagnosed with patchy gastric ischemia from the gastroesophageal junction to the distal gastric body. Though attempts were made to preserve his stomach, he eventually required a proximal subtotal gastrectomy with Roux-en-Y esophagojejunostomy with a gastrostomy tube in the antral remnant. SMA syndrome is an exceedingly rare cause of severe gastric dilation leading to necrosis and ultimately gastric perforation. Risk factors include weight loss, hypermetabolic activity, congenital abnormalities; although up to 40% of cases are idiopathic. Gastric dilation caused by duodenal compression from SMA syndrome can lead to high intragastric pressure which exceeds the gastric venous pressure resulting in mucosal ischemia. We suspect that this patient's disease process was able to progress to the level of causing gastric ischemia in large part due to his lack of pain sensation caused by the severe distention.