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case_images: CT examination performed at another hospital before admission into our hospital. Marked enlargement of the area from the stomach to the descending part of the duodenum was observed.. CT: computed tomography.
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case_images: Abdominal computed tomography (CT) showed marked enlargement of the area from the stomach to the descending part of the duodenum, and a change in the caliber of the horizontal part of the duodenum behind the aorta (Figure 1), leading to the diagnosis of SMA syndrome.
case_images: Upper gastrointestinal endoscopy: (a) the 12th day of the disease: ulceration was found across a wide area of the stomach body. A filthy cloudy coating was observed across the entire stomach. Enterobacter cloacae and Enterococcus faecium were detected in culture; and (b) the 38th day of the disease: the ulceration across the entire stomach body had not improved, and bile-trapping and an exudate were observed. A stricture was present in the mid-part of the stomach.
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case_images: Upper gastrointestinal endoscopy performed on the 12th day of the disease confirmed the presence of ulceration across a wide area of the stomach body (Figure 2(a)). It was impossible to insert an endoscope into the duodenum due to stricture in the mid-part of the stomach (Figure 2(b)).
case_images: Biopsy: 38th day of the disease (hematoxylin and eosin (HE) staining). Severe erosion was observed, the majority of the epithelium was peeled off, and granulation tissue was present.
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case_images: Examination of biopsy specimens from the upper part of the greater curvature confirmed severe erosion and granulomatous change (Figure 3).
case_images: Upper gastrointestinal endoscopy findings (90th day of the disease). Gradual epithelialization was observed. An endoscope could not be passed through the stomach cavity because of progressive stricture in the body of the stomach.
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case_images: Furthermore, the stricture in the mid-part of the stomach had worsened (Figure 4).
case_images: Upper gastrointestinal series findings. Strictures of the stomach body and difficulties in passage of contrast agent were observed. Gastric peristalsis was absent, and a small amount of the contrast agent came out upon changes in position. Significant reflux toward the esophagus was observed.
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case_images: Gastric peristalsis was absent: a small amount of contrast agent came out of the stomach cavity upon changes in position, and significant esophageal reflux was observed (Figure 5).
case_images: Macroscopic findings of the surgically resected specimen. Thickening of the entire wall was observed, and the lengths of the greater curvature and the lesser curvature were apparently shortened by 9 and 7 cm, respectively. Increased wall thickness and fibrosis were observed from the upper to the lower part of the stomach body, while antral distension was relatively preserved. The greater omentum was only mildly cloudy.
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case_images: The greater omentum was only mildly cloudy (Figure 6).
case_images: Pathological findings: (a) a microscopic image of the lesser curvature of the stomach. In the mucosal layer, epithelial shedding and granulation were observed. Fibrosis as well as arterial obstruction (arrow) and organized thrombus (arrow head) were prominent in and below the submucosa; (b) a high-power view of the mucosa. Granulation was observed in the superficial layer; (c) a high-power view of the deeper layer. Foamy cells and multinucleated giant cells, indicative of chronic inflammation and fibrosis, were present; and (d) a microscopic image of the ulcer margin. Active inflammation and erosion were observed in the left part of the section, while preserved epithelium and mild inflammation were seen in the right part of the section. The border of the ulceration was relatively clear.
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case_images: The border of the ulcer in the antrum showed fibrotic foci that were clearly distinguishable from the normal mucosa, suggesting blood supply-dependent ischemia (Figure 7(a)-(d)).