A 51 y.o. woman presents with L flank pain and pelvic pain.

what do you see?

hint the arrow is pointed at dilated veins

Could there be a cause of dilated veins higher in the abdomen?

Our patient had pelvic congestion from the nutcracker syndrome. This was first reported in 1950 by El-Sadr and Mina.  It consists of compression of the renal vein on the L between the aorta and the superior mesenteric artery.  This causes dilation of the vein and the development of collaterals.   The venous return from the L gonadal vein returning to the L renal vein is blocked and can cause testicular pain or varicoceles. Hematuria is the most frequent reported complication in children.  In children the condition often disappears as they gain weight since the fat in the retroperitoneum lifts the superior mesenteric artery off the renal vein.

The classic presentation is flank pain as in our patient.  Patients may have proteinuria depending on if they are sitting or standing. Ovarian veins can dilate leading to increased pain during menses.

Doppler US or CT can be used to make the diagnosis.   On US, the AP diameter of the vein is measured   and a peak systolic velocity at least four times as fast as an uncompressed vein is diagnostic. A venogram can be performed with a renocaval pullback gradient of >3 being diagnostic.  The differential includes compression of the renal vein by pancreatic cancer, retroperitoneal tumors or abdominal aortic aneursyms.

the pancreas can push down on the superior mesenteric artery causing nutcracker syndrome in cases of cancer

Treatment depends on the severity of symptoms with renal vein reimplantation being the most extreme.  Stents and gonadal vein embolization are also used.  Our patient was referred to vascular for possible stenting.

Kurklinsky A, Rooke T. Nutcracker phenomenon and nutcracker syndrome. 2010 Mayo Clinic Proceedings. 85(6):552-9.

White J, Comerota A. Venous compression syndromes. 2017 Vascular and Endovascular surgery. 51(3):155-68.

Mohammadi A, Mohamadi A, Ghasemi-Rad M, et al. Varicocele and nutcracker syndrome: sonographic findings. 2002 Australasian Radiology 46(2):197-200.

El-Sadr A, Mina E. Anatomical and surgical aspects in the operative management of varicocele. Urol Cutaneous Rev. 1950;54(5):257-262.