Coexistant Superior Mesenteric Artery Syndrome and Nutcracker Syndrome: A Case Report and Review of Literature

Background Superior mesenteric artery syndrome orWilkie's syndrome is a rare condition consisting of external compression of the third part of duodenum between the Superior mesenteric artery and the aortorachidian plan resulting in duodenal obstruction. The vascular compression of the duodenum is a very rare condition exceptionally associated to Nutcracker syndrome an uncommon vascular abnormality which is caused by external compression of the left renal vein. Case presentation We report a case of a 27-year-old man admitted to our department with a history of severe weight loss, post prandial epigastric abdominal pain with anorexia and occasional vomiting over the past two years. He repored two episodes of macroscopic hematuria. Physical examination revealed a cachectic patient with a body mass index of 14kg/m2. The abdomen was tender with distension. Laboratory studies revealed a mild anemia and hypoalbuminemia with no other abnormalities. An abdominal CT scan showed a massive gastric and dilated proximal duodenum, with the compression of the third portionof the duodenum between the aorta and the Superior mesenteric artery. In addition, the left renal vein was compressed by the Superior mesenteric artery. The diagnosis of Superior mesenteric artery syndrome associated to Nutcracker syndrome was made. Conservative treatment (correction of electrolyte imbalance, enteral nutrition) fails. The patient was treated surgically with gastrojejunostomy in order to gain weight and to reduce pain. Conclusions Superior mesenteric artery syndrome and Nutcracker syndrome are uncommon vascular abnormalities, exceptionally associated. The diagnosis is most of the time a challenging and must be considered in the differential diagnosis of gastro-intestinal obstruction and unknown cause of hematuria. CT findings could be helpful for the diagnosis. Most of the time the conservative treatment with adequate nutrition will result in weight gain. Surgical option can be considered when conservative treatment fails.