Question

5 year-old male with developmental delay presents with intractable non-bloody and non-bilious vomiting over 10 days; bowel movements are normal. Four weeks ago he was placed in a hip-spica cast following a motor vehicle crash. Abdominal x-ray is below. Diagnosis?

Answer

Answer: CAST syndrome (also known as Superior Mesenteric Artery Syndrome)

• Caused by extrinsic compression of the SMA with ensuing partial gastric outlet obstruction

• Commonly seen in the second decade of life when there is increased spinal flexibility and truncal casting increases lumbar lordosis. This changes the take-off of the SMA which crosses the horizontal part of the duodenum.

• Those at risk include those with patients with spinal disease, hip and pelvic fractures.  Children with disabilities who have poor fat mass, hypotonicity, and skeletal distortion may also be affected.

• Clinical symptoms include nausea, vomiting, abdominal distention which may lead to dehydration, metabolic alkalosis and shock and sometimes death.

• Treatment includes IV replacement therapy, NG tube to decompress the stomach and duodenum and replacement of the cast.

References

Wheeless Textbook of Orthopedics. Updated August 29,2011

Lichenstein, R. Radiology Cases in Pediatric Emergency Medicine, Volume 5, Number 16

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