Working Diagnosis:
Superior mesenteric artery (SMA) syndrome due to anorexia nervosa

Treatment:
In the hospital setting, the patient’s electrolytes were repleted. She was monitored with cardiac telemetry until her conduction abnormalities resolved. Emesis of the majority of her meals continued with modest relief with anti-emetic medication. The consulting gastroenterologist thought the patient’s dramatic weight loss was due to anorexia and subsequent loss of the SMA fat pad resulting in SMA syndrome. A naso-jejunal tube was attempted, but the patient did not tolerate it. Interventional radiology then placed a gastro-jejunal tube and tube feeds were started. She was monitored for refeeding syndrome. She gained 10 pounds over the 18 days of her admission. Psychiatry was consulted and recommended continued outpatient therapy for anorexia but the patient continued to deny she had an eating disorder.

Outcome:
The patient returned to college the next fall and presented for a pre-participation physical for rowing. She denied nausea, vomiting, or restricting her diet. She reported improved mood. Her weight at the first visit was 118 pounds, still underweight. A plan was developed to return her activity. To participate in rowing, she was required to maintain a weight of 125 pounds, which correlates to a BMI of 18.5. She was also required to attend monthly visits with a psychologist, nutritionist, and team physician.

She gained 7 pounds over the next two weeks. But it became clear that she had water loaded prior to her visit because her urine was dilute. While she had not been allowed to train with the crew team, she had been training on her own for a half marathon, was lifting weights, and attending a yoga class. She was advised that water loading was not an appropriate method to increase her weight and she was directed to stop training for the half marathon.

Editor's Comments:
Superior Mesenteric Artery Syndrome is a rare entity. The most common cause is significant weight loss causing atrophy of the mesenteric fat pad typically from malignancy, AIDS, malabsorption syndromes, and burns. It has also been described after bariatric surgery. Anatomic causes exist as well, most commonly after surgical correction of scoliosis, but it can also be caused by congenital variations (rare).
Diagnosis is typically made on upper GI with small bowel follow through or CT/MRI.
The mainstay of treatment is nutritional support and in many cases a nasojejunal tube is required. In severe cases, TPN may be required.
Despite this patient's denial of disordered eating, other objective clues to the presence of an eating disorder seen in this patient include the following: bradycardia, hypokalemia, amenorrhea and lanugo.

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