In medicine

Medicine

Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....

, the nutcracker syndrome (NCS) — is a clinically manifest variant of nutcracker phenomenon, renal vein entrapment syndrome, or mesoaortic compression of the left renal vein. It results most commonly from the compression of the left renal vein

Renal vein

The renal veins are veins that drain the kidney. They connect the kidney to the inferior vena cava.It is usually singular to each kidney, except in the condition "multiple renal veins".It also divides into 2 divisions upon entering the kidney:...

 between the abdominal aorta

Abdominal aorta

The abdominal aorta is the largest artery in the abdominal cavity. As part of the aorta, it is a direct continuation of the descending aorta .-Path:...

 (AA) and superior mesenteric artery

Superior mesenteric artery

In human anatomy, the superior mesenteric artery arises from the anterior surface of the abdominal aorta, just inferior to the origin of the celiac trunk, and supplies the intestine from the lower part of the duodenum through two-thirds of the transverse colon, as well as the pancreas.-Location...

 (SMA), although other variants exist. The name derives from the fact that, in the sagittal view, the SMA and AA (with some imagination) appear to be a nutcracker

Nutcracker

A nutcracker is a mechanical device for cracking nuts. Usually they work on the principle of moments as described in Archimedes' analysis of the lever...

 crushing a nut

Nut (fruit)

A nut is a hard-shelled fruit of some plants having an indehiscent seed. While a wide variety of dried seeds and fruits are called nuts in English, only a certain number of them are considered by biologists to be true nuts...

 (the renal vein).
There is a wide spectrum of clinical presentations and diagnostic criteria are not well defined, which frequently results in delayed or incorrect diagnosis.
This condition is not to be confused with superior mesenteric artery syndrome

Superior mesenteric artery syndrome

Superior mesenteric artery syndrome is a very rare, life-threatening gastro-vascular disorder characterized by a compression of the third portion of the duodenum by the abdominal aorta and the overlying superior mesenteric artery...

, which is the compression of the third portion of the duodenum by the SMA and the AA.

Signs and symptoms

NCS is associated with hematuria

Hematuria

In medicine, hematuria, or haematuria, is the presence of red blood cells in the urine. It may be idiopathic and/or benign, or it can be a sign that there is a kidney stone or a tumor in the urinary tract , ranging from trivial to lethal...

 (which can lead to anemia

Anemia

Anemia is a decrease in number of red blood cells or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin...

) and abdominal pain

Abdominal pain

Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem...

 (classically left flank pain).

Since the left gonad

Gonad

The gonad is the organ that makes gametes. The gonads in males are the testes and the gonads in females are the ovaries. The product, gametes, are haploid germ cells. For example, spermatozoon and egg cells are gametes...

 drains via the left renal vein

Renal vein

The renal veins are veins that drain the kidney. They connect the kidney to the inferior vena cava.It is usually singular to each kidney, except in the condition "multiple renal veins".It also divides into 2 divisions upon entering the kidney:...

 it can also result in left testicular pain in men or left lower quadrant pain in women. Nausea

Nausea

Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...

 and vomiting

Vomiting

Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...

 can result due to compression of the splanchnic veins. An unusual manifestation of NCS includes varicocele

Varicocele

Varicocele , also known as varicoscele or varicose seal, is an abnormal enlargement of the vein that is in the scrotum draining the testicles. The testicular blood vessels originate in the abdomen and course down through the inguinal canal as part of the spermatic cord on their way to the testis...

 formation and varicose veins in the lower limbs.. Another clinical study has shown that that nutcracker syndrome is a frequent finding in varicocele-affected patients and possibly, nutcracker syndrome should be routinely excluded as a possible cause of varicocele .

Diagnosis

Nutcracker syndrome can be diagnosed with:

• Left renal venography
  Venography
  Venography is a procedure in which an x-ray of the veins, a venogram, is taken after a special dye is injected into the bone marrow or veins. The dye has to be injected constantly via a catheter, making it an invasive procedure...
  
   — considered to be the gold standard test
  Gold standard (test)
  In medicine and statistics, gold standard test refers to a diagnostic test or benchmark that is the best available under reasonable conditions. It does not have to be necessarily the best possible test for the condition in absolute terms...
  
  .
• Computed tomography
  Computed tomography
  X-ray computed tomography or Computer tomography , is a medical imaging method employing tomography created by computer processing...
  
   (CT).
• Abdominal ultrasonography — not definitive but has been found to be useful.

Differential diagnosis

• Renal stones
• Genitourinary malignancy
• Loin pain hematuria syndrome
  Loin pain hematuria syndrome
  Loin pain hematuria syndrome, also LPHS, is the combination of unilateral or bilateral flank pain and microscopic or macroscopic amounts of blood in the urine that is otherwise unexplained.-Diagnosis:LPHS is considered a diagnosis of exclusion...
  
  

Treatment

Treatment depends on the severity and symptoms. Treatments include:

• Endovascular stenting.
• Renal vein re-implantation.
• Gonadal vein
  Gonadal vein
  In medicine, gonadal vein refers to the blood vessel that carrying blood away from the gonad toward the heart.* Females : ovarian vein* Males : testicular vein...
  
   embolization
  Embolization
  Embolization is a non-surgical, minimally-invasive procedure performed by an interventional radiologist and interventional neuroradiologists. It involves the selective occlusion of blood vessels by purposely introducing emboli.-Therapeutic applications:...
  
  .