NUTCRACKER SYNDROME: A REPORT OF TWO CASES

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A.A. Adejumo¹, B.E. Osobu²

1. Department of Surgery, Federal Medical Centre, Keffi, Nassarawa State.
2. Department of Radiology, Turaif General Hospital, Northern Borders, Saudi Arabia.

Abstract

Introduction: Nutcracker syndrome is a pathology that could pose a diagnostic conundrum to the physician as the patient could present with vague symptoms. This report brings to limelight the pathology of Nutcracker syndrome and the need for clinicians to consider this as a differential diagnosis when managing patients with non-specific abdominal pain.

Case presentation: This is a case series report of two patients that presented at the emergency unit with acute exacerbation of insidious onset of upper abdominal pain. Radiological evaluation with computerized tomography proved the presence of this pathology in both patients with reduction in aortomesenteric angles and distances. The management of this clinical entity is largely conservative with surgical intervention rarely needed.

Conclusion: Radiological evaluation is the bedrock of diagnosis of Nutcracker syndrome. The clinician should endeavor to consider this as a differential diagnosis in patients with recurrent and undefined upper abdominal symptoms.

Keywords: Nutcracker syndrome, Abdominal pain, Radiology

Introduction

Nutcracker syndrome (NS), also called left renal vein (LRV) entrapment syndrome, is a rare vascular compression disorder referring to extrinsic compression of the LRV by the superior mesenteric artery (SMA) anteriorly and the aorta posteriorly.¹ It can lead to lead to renal vascular congestion manifesting as hematuria, proteinuria, orthostatic hypotension, pain or renal dysfunction.² The severity of the NS is variable and affected individuals may be completely asymptomatic, in which case it is referred to as nutcracker phenomenon, or in the most severe cases, experience severe pelvic congestion.³ NS may be associated with a SMA compression disorder where the SMA compresses the third part of the duodenum.⁴ Diagnosis can be challenging and variable, frequently involving a combination of Ultrasound Doppler, cross-sectional, and invasive imaging.⁵ Management depends on severity of clinical features. Treatment ranges from expectant management to surgical intervention.

Case Presentation 1
HSH, a 20-year-old male adult, presented to the emergency room with acute exacerbation of chronic upper abdominal pain. The pain was described as dull and dragging, with associated nausea and occasional vomiting. He has been to other hospitals in the years past for similar presentation. There was no history of blunt trauma to the abdomen and no history of abdominal surgery. Clinical examination revealed a young man, well preserved, not pale, hydrated with stable vital signs. Abdomen is flat, with diffuse and vague tenderness in the epigastric and peri-umbilical regions, no positive, expansile cough impulse. Abdominal sonography done was essentially normal. He later had an abdominal computerized tomography (CT) scan done that revealed an aortomesenteric distance of 5-6mm, while aortomesenteric angle was 140, with left renal vein compressed between the SMA and the aorta. All laboratory investigations were essentially normal.

Case Presentation 2
AMA, 29 year old, male patient who presented to the surgical out-patient clinic with recurrent upper abdominal pain, nausea with occasional vomiting. Patient also has a history of Crohn’s disease and he has been receiving treatment for this. Clinical examination shows a young man, well preserved with stable vital signs. Abdominal examination showed a flat abdomen, with mild tenderness on deep palpation at the epigastrium. All laboratory parameters were within normal limits. Abdominal sonography was equivocal while he has abdominal CT scan done which revealed the presence of Nutcracker syndrome (Illustration 2). He was counselled and referred to the gastrointestinal surgery unit for further follow-up.