Abstract: SA-PO304
A Diagnostic Challenge: Acute Nutcracker Abdomen
Session Information
- Trainee Case Reports - VI
October 27, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 1302 Health Maintenance, Nutrition, and Metabolism: Clinical
Authors
- Venkataraman, Sandheep, Montefiore Medical Center, Bronx, New York, United States
- Kang, John S., Metropolitan Hospital Center, New York, New York, United States
- Lwin, Lin N., Montefiore Medical Center, Bronx, New York, United States
Introduction
Nutcracker syndrome or left renal vein entrapment syndrome is a rare condition caused by the compression of left renal vein between the abdominal aorta and superior mesenteric artery (SMA). We describe the case of a young female presenting with intractable pain.
Case Description
26-year old woman with history of recently diagnosed untreated H. pylori gastritis presented with sudden onset severe abdominal pain which lasted three weeks. The pain was sharp and worsened with food intake. She denied fever, nausea, vomiting, blood in urine, or recent NSAID use. She was tender to palpation over right and left upper quadrants of abdomen. Labs were normal. CT scan with IV contrast revealed left renal vein compressed between the aorta and the SMA, congested left kidney, medullary edema, and numerous retroperitoneal venous collaterals. This was thought to be incidental. She was diagnosed as gastritis and discharged on H. pylori treatment. However, she returned one month later with persistent abdominal pain. Renal doppler ultrasound showed significant narrowing of left renal vein with significant velocity gradient, consistent with Nutcracker syndrome. Contrast venography revealed proximal left renal vein narrowing, with elevated distal left renal vein pressure, which resolved with stent placement. She became pain-free after the procedure.
Discussion
Nutcracker syndrome was first described in 1937. It occurs due to an idiopathic decrease in the angle between the aorta and the SMA (to less than 35 degrees), with consequent compression of the left renal vein. It is most often asymptomatic, painless, and requires a high index of suspicion to diagnose. Serum biochemistry and urinalysis are often unremarkable. Our patient presented atypically with only acute abdominal pain, which can have a broad differential, making this diagnosis easy to miss. In some cases of nutcracker syndrome, severely increased pressure can lead to abnormal thin-walled collaterals which rupture leading to gross or microscopic hematuria, which was not seen in our patient. The diagnosis is usually made based on degree of stenosis and increased flow velocity as seen on doppler ultrasound. Venography is confirmatory. Treatment can be conservative or surgical. Given the rarity of the condition and limited evidence, the long-term prognosis remains to be elucidated.