Superior mesenteric artery syndrome with anterior nutcracker syndrome
Presentation
Repeated attacks of post-prandial vomiting - Hematuria
Patient Data
Distended stomach, 1st and 2nd parts of the duodenum. The 3rd part of the duodenum is compressed between the aorta and the superior mesenteric artery. These findings are suggestive of superior mesenteric artery syndrome.
Engorged dilated left renal vein with abrupt caliber change at the point of its passage between the aorta and superior mesenteric artery. The findings correlate with anterior nutcracker syndrome.
Narrow aorto-mesenteric angle with an abrupt origin of the superior mesenteric artery from the aorta.
The aorto-mesenteric distance measures 4.48 mm (Normally= 10-28 mm). The aorto-mesenteric angle measures 20.3 degrees (Normally= 25-60 degrees) 3.
Case Discussion
Superior mesenteric artery (SMA) syndrome is a rare cause of proximal bowel obstruction. Decreasing the aorto-mesenteric angle to less than 25 degrees or decreasing the aorto-mesenteric distance to less than 10 mm causes compression of the 3rd part of the duodenum between the aorta and the superior mesenteric artery. Surgical management of SMA syndrome includes gastro-jejunostomy, Strong procedure (the division of the ligament of Trietz), and duodeno-jejunostomy.
The anterior nutcracker phenomenon refers to the compression of the left renal vein between the aorta and the superior mesenteric artery. When this compression becomes clinically significant, it is referred to as the anterior nutcracker syndrome. Its symptoms vary from subtle hematuria to pelvic congestion. Conservative treatment is reserved for mild cases of hematuria. The most common and effective surgical management is the transposition of the left renal vein.