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This case report presents the diagnosis of superior mesenteric artery and nutcracker syndromes in a previously fit and well 14-year-old girl. Although these two entities usually occur in isolation, despite their related aetiology, our patient was a rare example of their occurrence together. In this case the duodenal compression of superior mesenteric artery syndrome caused intractable vomiting leading to weight loss, and her nutcracker syndrome caused severe left-sided abdominal pain and microscopic haematuria without renal compromise. Management of the superior mesenteric artery syndrome can be conservative by increasing the weight of the child which leads to improvement of retroperitoneal fat and hence the angle of the artery. The weight can be improved either by enteral feeds or parenteral nutrition. This conservative management initially helped but not in the long-term as the child started losing weight again. The next step in management is surgery (duodenojejunostomy – if the conservative management fails), which the child went through, remarkably improving their symptoms.
In the absence of certainty regarding the causes of both inflammatory bowel disease (IBD) and its extraintestinal manifestations (EIMs), there is necessarily ambiguity in both academic and clinical arenas concerning the diagnosis, classifications, and treatments of EIMs. While the “true” EIMs are considered extensions of the IBD gut pathogenesis with an immunologically mediated inflammatory consequence, other EIMs are considered to be complications of IBD itself or its treatment. A third group of IBD EIMs includes those disorders which seem to occur more often in IBD but for which an etiologic or pathophysiologic connection to IBD is highly theoretical. Patients with IBD and EIMs tend to have more severe, long-duration disease, and a reduced quality of life. EIMs presentation may or may not parallel IBD gut inflammatory activity. The clinical decision-making processes necessary for successfully managing simultaneously the gut component of IBD and its EIMs are presented. Based upon clinical experience and review of leading publications, the consensus of best practices, differential diagnoses for EIMs, and
current management programs are presented with enumeration of specific decisions and considerations required for successful management of EIMs. EIMs of inflammatory bowel disease reflect the immunopathologic common ground and hence the systemic nature of the IBD. A defined decision-making process is offered which includes consultations and attention to the differential diagnosis to avoid not uncommon mistakes in diagnosis. Management of all EIMs requires assessment of both the clinical and pathologic status
of the gut component of IBD combined with judicious selection of general and /or immunosuppression therapy for the EIMs.
Ulcerative colitis; Crohn’s disease; Erythema nodosum; Pyoderma gangrenosum; Primary sclerosing cholangitis; Spondyloarthritis; Uveitis; Paradoxical dermatitis.
letter to the editor
Functional disorders of the digestive tract are a common occurrence in the doctor’s office. In addition to functional dyspepsia, 35% of dyspepsia are unresolved dyspepsia, which are a symptom of the early stage of pancreatic exocrine insufficiency.
Based on clinical experience, we can suspect and detect chronic pancreatic insufficiency at an early stage, which is the aim of this paper.
To demonstrate the efficacy of enzyme replacement therapy in the early stage of pancreatic exocrine insufficiency using the case report of the patient.
Results confirms significance and effectiveness of creon as an enzyme replacement therapy in the treatment of malabsorption and maldigestion.
Creon (pancreatin) showed great effect in the treatment of dyspepsia and anorexia nervosa, body mass index (BMI) for 30 days increased from 15.9 to 17.4, which leads us to the conclusion that unrecognized chronic pancreatic insufficiency can be expected in long-term dyspepsia.
Chronic pancreatic insufficiency; Enzyme; Body mass index (BMI); Digestive tract.
Assistant Professor Division of Digestive Diseases and Nutrition Department of Internal Medicine University of Kentucky Lexington, KY 40506, USA
Associate Professor Department of Surgery Institute of Molecular Medicine Trinity Centre for Health Sciences St James Hospital Dublin 8, Ireland
Department of of Interventional Gastroenterology Moffitt Cancer Center Department of Gastroenterology Kansas University Medical Center 235 Ward Parkway, Apt 307 Kansas City, MO-64112, USA