Background and Clinical Significance: Annular pancreas is a rare congenital anomaly in which pancreatic tissue partially or completely encircles the duodenum, potentially causing duodenal obstruction. Clinical presentation varies from asymptomatic cases to persistent vomiting, feeding intolerance, and failure to thrive, often leading to delayed diagnosis. Case Presentation: We report a 2-year and 10-month-old girl with a long-standing history of intermittent, recurrent vomiting since the neonatal period, without growth impairment or other alarming symptoms. Initial imaging suggested proximal duodenal dilation, with suspicion for superior mesenteric artery (SMA) syndrome. Endoscopy revealed mechanical obstruction at the second portion of the duodenum. Contrast-enhanced CT confirmed annular pancreas partially encircling the duodenum. The patient underwent duodeno-duodenostomy with an uneventful postoperative course and complete resolution of symptoms. This case illustrates the diagnostic challenges of annular pancreas in older children with atypical presentations. Multimodal imaging is crucial for accurate diagnosis. Surgical bypass remains the definitive treatment, offering excellent long-term outcomes. Conclusions: Persistent or recurrent vomiting in children, even without classic signs such as bilious vomiting or failure to thrive, should prompt consideration of annular pancreas. Early recognition and timely surgical intervention can prevent prolonged morbidity and ensure normal growth and development.

Background and Clinical Significance: Superior mesenteric artery syndrome (SMAS) is a rare and often underdiagnosed cause of proximal intestinal obstruction, resulting from compression of the third portion of the duodenum between the SMA and the aorta. It typically occurs in individuals with significant weight loss due to mesenteric fat depletion. Case Presentation: We report the case of a 14.5-year-old female presented with a 6-day history of intractable vomiting and epigastric pain, on a background of intermittent vomiting over the preceding six months associated with a 7 kg unintentional weight loss, culminating in inability to tolerate oral intake. Her clinical course was complicated by a transient episode of blurred vision, numbness, and incoherent speech, initially suspected to be a neurological event. Extensive gastrointestinal and neurological investigations were inconclusive. Elevated fecal calprotectin levels raised suspicion for inflammatory bowel disease, given her family history, though endoscopy and histopathology were unremarkable. Advanced imaging ultimately demonstrated a markedly reduced aortomesenteric angle (6°) and distance (4 mm), confirming the diagnosis of SMAS. The patient was initially managed conservatively with total parenteral nutrition (TPN), achieving partial weight gain of 5 kg after 8 weeks of TPN. Due to persistent duodenal compression, surgical intervention was required. At 7-month follow-up, the patient remained symptom-free with restored nutritional status and a good weight gain. Conclusions : This case highlights the importance of considering SMAS in adolescents with chronic upper gastrointestinal symptoms and significant weight loss. Early recognition and appropriate imaging are essential to diagnosis, and timely surgical management can lead to excellent outcomes when conservative treatment is insufficient.