Nutcracker Syndrome Masquerading as Renal Colic in an Adolescent Athlete: A Case Report

Abstract

Introduction: Abdominal pain and flank pain cause a significant proportion of emergency department (ED) visits. The diagnosis often remains unclear and is frequently associated with repeat visits to the ED for the same complaint. A rare cause of left upper abdominal and flank pain is compression of the left renal vein between the aorta and the superior mesenteric artery known as nutcracker syndrome. Diagnostic findings on ultrasound include increased left renal vein diameter proximal and peak blood flow velocity increase distal to the superior mesenteric artery. We describe such a patient presenting to an ED repeatedly with severe pain mimicking renal colic before the final diagnosis and intervention occurred. Case Report: A 16-year-old female, long-distance runner presented four times complaining of intractable left upper quadrant abdominal pain radiating to the left flank after exercise. On each visit urinalysis revealed proteinuria and hematuria, and on two visits abdominal computed tomography revealed no kidney stone or dilatation of the collecting system. Ultimately, she was referred to vascular surgery where Doppler ultrasonography was used to diagnose left renal vein compression. Transposition of the left renal vein improved Doppler diameter and flow measurements and eliminated symptoms. Conclusion: Emergency physicians must maintain a large list of possible diagnoses during the evaluation of abdominal and flank pain with a repetitive and uncertain etiology. Nutcracker syndrome may mimic other causes of abdominal and flank pain such as renal colic and requires appropriate referral.

Nutcracker syndrome in childhood

“…18,19 Approximately 10% of pediatric cases may present with atypical diffuse abdominal pain secondary to pelvic venous compression. 3,[18][19][20] Both flank and abdominal pain may occur in these patients due to the activation of the inflammatory cascade triggered by venous hypertension. 4 Hypertension is not a classic symptom of NCS, and only a few cases of NCS associated with hypertension have been identified in children.…”