1Division of Gastroenterology; 2Department of Radiology, Lenox Hill Hospital, New York, New York, USA Correspondence: Dr Truptesh H Kothari, Division of Gastroenterology, Lenox Hill Hospital, 100 East 77th Street, New York, New York 10075, USA. Telephone 212-434-2176, fax 678-716-8710, e-mail itskots@gmail.com Received for publication September 14, 2011. Accepted September 26, 2011 case presentation A 24-year-old woman with no significant medical history presented to the hospital with complaints of nausea and vomiting for one day. The patient had experienced associated symptoms of abdominal distension, which worsened after meals, for the previous six months. The patient denied weight loss. The laboratory results were unremarkable. On physical examination, her abdomen was soft, with minimal tenderness in the epigastric area without guarding or rigidity. Bowel sounds were heard in all four quadrants, and there were no signs of organomegaly, ascites or asterixis. Diagnosis superior mesenteric artery syndrome An abdominal computed tomography (CT) scan with contrast revealed the narrowing of the third portion of the duodenum compressed by the superior mesenteric artery (SMA), with dilation of the portion of the duodenum proximal to the compression. An abdominal CT scan and ultrasound with Doppler was used to measure the aortomesenteric (AO) angle and the AO distance. The normal AO angle is between 45° and 60° (1); the AO angle in this patient was 18° (Figure 1). The normal AO distance is between 10 mm and 20 mm (1); the AO distance in this patient was 5 mm to 6 mm (Figures 2 to 4); hence, the diagnosis was consistent with SMA syndrome.