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Nutcracker Syndrome As An Unusual Cause Of Post-prandial Pain
Krystal Maloni, MD, Keith Calligaro, MD, William Lipshutz, MD, Kunal Vani, DO, Douglas Troutman, DO, Matthew Dougherty, MD.
Pennsylvania Hospital, Philadelhpia, PA, USA.

Demographics:
We report a patient with nutcracker syndrome who presented atypically with left flank pain that was exacerbated by oral intake. We hypothesize that physiologic dilation of the SMA after ingestion caused worsening left renal vein (LRV) compression and augmented LRV distention, manifesting as pain. Symptoms resolved after we performed a left ovarian vein (LOV) to inferior vena cava (IVC) transposition.
History:
A 50-year-old healthy female presented with a 4-month history of intermittent left flank pain exacerbated by eating, in addition to a 5-pound weight loss. Postprandial pain was partially relieved by lying in the left lateral decubitus position. Abdominal MRI showed compression of the LRV between the SMA and aorta as well as a dilated LOV and no compression of the duodenum by the SMA. An abdominal duplex ultrasound confirmed these findings.
Plan:
LOV transposition was performed as treatment. A midline incision was made, the colon was retracted cephalad, and the small bowel was retracted to the right. The LOV was easily identified due to its large diameter. The LOV was dissected from the pelvic brim to its confluence with the LRV. The IVC was dissected circumferentially inferior to the renal veins.
The LOV was ligated near the pelvic brim and was tunneled posterior to the inferior mesenteric vein. A side biting clamp was applied to the IVC. The spatulated end of the LOV was sutured to the IVC as an end-to-side anastomosis (Fig. 1).
The patient had an unremarkable post-op. At a two week follow up visit, the patient noted remission of left flank and post-prandial pain. Duplex scan documented flow from the LRV through a widely patent LOV transposition bypass into the IVC.
Discussion:
In this patient with nutcracker syndrome, we suspect that physiologic dilation of the SMA after oral intake caused further compression of the LRV and a worsening of the patientís left flank pain. Her pain improved by assuming the left lateral decubitus position, possibly increasing the angle between the SMA and aorta and decompressing the LRV. Resolution of symptoms after LOV transposition lends credence to this theory.


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