superior mesenteric artery syndrome is an uncommon cause of duodenal obstruction , and its manifestations are generally associated with compression on the third part of the duodenum between the abdominal aorta and superior mesenteric artery .
in this report , a patient is described presenting with epigastric pain and weight loss due to superior mesenteric artery syndrome .
the patient has also nutcracker syndrome , which is the compression of the left renal vein between the aorta and the superior mesenteric artery at its origin .
in addition to an appropriate clinical history , ct findings indicating decreased aortomesenteric angle and a shortened aortomesenteric distance can suggest the diagnosis for both the superior mesenteric artery syndrome and accompanying nutcracker syndrome .
superior mesenteric artery ( sma ) syndrome is a rare cause of abdominal pain , nausea , and vomiting that may be undiagnosed in patients presenting to the emergency department .
sma syndrome is arteriomesenteric obstruction of the duodenum , which is characterized by compression of the third portion of the duodenum by sma ( as it passes over this portion of the duodenum ) .
nutcracker syndrome ( ncs ) is characterized by impeded outflow from the left renal vein ( lrv ) into the inferior vena cava ( ivc ) due to extrinsic lrv compression .
we presented this case report in order to discuss the diagnosis of a patient with both sma syndrome and accompanying ncs with computed tomography ( ct ) findings .
a 28-year - old man was admitted to kirikkale university medicine faculty , radiology department , kirikkale , turkey , on 26 april 2013 . he had a history of 1-day vomiting , epigastric pain , and bloating ( table 1 ) .
he also reported weight loss , anorexia and intermittent abdominal pain during the past few years .
blood test results were as follows : mean corpuscular hemoglobin concentration , 36.3 g / dl ; granulocyte ( percentage , count ) , % 77 , 8  10/ul ; creatinine 0.61 mg / dl , with no other abnormalities . urinalysis revealed no hematuria .  
abbreviations : mchc , mean corpuscular hemoglobin concentration ; lrv , left renal vein ; ct , computed tomography .  
the scan was performed with ge hi - speed , a dual - detector ct scanner , which is regularly calibrated .
ct images showed the reduction of the angle between the abdominal aorta ( aa ) and sma , and decreased aortomesenteric distance .
the angle between the aa and sma was 14.30 ( figure 1a ) , and the aortomesenteric distance was 3.9 mm ( figure 1b ) .
gastric and proximal duodenal dilatation was observed ( figure 1c ) with the compression of the duodenal lumen between the aa and sma ( figures 1d and 1e ) .
the lrv was also compressed by the sma close to its origin , resulting in proximal dilatation ( figure f ) .
a ) sagittal ct scan showing the reduction of the angle ( 14 30 ) between the abdominal aorta and superior mesenteric artery .
b ) axial ct scan showing decreased aortomesenteric distance ( 3 , 9 mm ) .
d ) sagittal ct scan of abdomen showing duodenal compression between the abdominal aorta and superior mesenteric artery ( d : duodenum , lrv : left renal vein ) .
e ) axial ct scan of abdomen demonstrating duodenal compression between the abdominal aorta and superior mesenteric artery ( d , duodenum ; sma , superior mesenteric artery ) .
f ) axial ct scan showing dilated left renal vein owing to superior mesenteric artery compressing ( white arrow ) .
sma syndrome is a rare condition where the third part of the duodenum is compressed between the sma and aa , leading to duodenal outlet obstruction .
the incidence of sma syndrome has been found to be between 0.013% and 0.3% of the general population ( 1 ) .
sma syndrome is more common in females , and usually occurs between 35 and 45 years of age .
clinical diagnosis of sma syndrome is rather challenging owing to nonspecific character of the signs and symptoms in the majority of the patients , requiring a radiological diagnosis or confirmation of diagnosis .
upper gastrointestinal barium x - ray may demonstrate gastric and duodenal dilatation , or blockade of barium flow from duodenum to jejunum .
an endoscopic gastroduodenoscopy or ct scan of the abdomen could be helpful for confirmatory studies .
these modalities may reveal the extrinsic compression of the third portion of the duodenum and the narrow angle between the aa and sma ( 2 ) .
radiographically , sma syndrome is characterized by several findings such as gastric and proximal duodenal dilatation with compression of the duodenum and dilatation of the left renal vein . in normal patients ,
the distance between the aa and sma ( aortomesenteric distance ) is 10 - 34 mm with aortomesenteric angle of 28-65 ( 3 , 4 ) .
angiographic studies have indicated that patients with sma syndrome have an abnormal aortomesenteric angle ( 6-22 ) , and a shortened aortomesenteric distance ( 2 - 8 mm ) compared to normal patients . in a study using multidetector computed tomography ( mdct ) , the average aortomesenteric angle in patients with sma syndrome was 13.5 , with an aortomesenteric distance of 4.4 mm . evidently , any absolute numerical cut - off is arbitrary , but some reports have advocated that an aortomesenteric distance < 8 mm and an angle < 22 are suggestive of the diagnosis providing the right clinical setting ( 5 ) .  
the lrv normally passes between the aa and sma , where it may be pressed , resulting in a variable degree of lrv obstruction .
this compression of lrv between aa and sma is entitled nutcracker syndrome ( ncs ) ( 6 ) .
the ncs is the clinical equivalent of nutcracker phenomenon ( ncp ) defined by a set of symptoms with significant alterations ( 7 ) .
while the terms ncp and ncs are sometimes used interchangeably in the literature , shin and lee accentuated that the nutcracker anatomy is not always accompanied with clinical symptoms and that some of the anatomic findings suggestive of nutcracker may stand for a normal variant or be accounted for by other conditions ( 8) .
imaging , such as ultrasonography ( us ) , doppler us , ct , or magnetic resonance imaging ( mri ) , is required to diagnose ncs .
acute narrowing of the lrv at the level of sma ( beak sign ) , lateral ( hilar ) dilatation and the presence of collateral pathways at ct imaging can be helpful for the diagnosis of ncs .
however , the diagnostic procedure ( considering the reference standard for establishing the diagnosis of ncs ) is invasive selective left renal phlebography with the measurement of the pressure gradient between the lrv and ivc ( 2 , 6 ) .
our patient had decreased aortomesenteric distance and aortomesenteric angle , dilated stomach and proximal duodenum and dilated lrv .
english literature search revealed one case in which sma syndrome was found in concomitance with ncp ( 4 ) .
sma syndrome accompanied by ncs , a rare collaboration , is the strong point of our study .
sma syndrome should be considered in the differential diagnosis of duodenal obstruction such as duodenal hypoplasia , duodenal stenosis , duodenal atresia , peptic ulcer disease , congenital bands , intestinal malrotation , annular pancreas , and pre - duodenal portal vein ( 2 ) .
most cases occur in patients with weight loss and reduction of fat stores around superior mesenteric artery because of a variety of reasons ( surgery , malabsorption , trauma , etc . )
( 3 ) . in the differential diagnosis of ncs , pathologies that cause pain , hematuria and proteinuria with an unexplained cause can be considered ( 6 ) .
conservative management based on the correction of electrolyte imbalance , and appropriate enteral or parenteral nutrition could result in symptomatic improvement and weight gain in most patients .
surgery , which may be considered if conservative treatment fails , involves the release of the treitz ligament . during surgery ,
the ligament may be simply released or reconstructive approaches such as the open or close laparoscopic duodenojejunostomy , or roux - en - y procedure are chosen ( 2 ) . in ncs management , supporting treatment is sufficient if the symptoms are minimal .
surgical or radiological treatments are indicated for severe pain , evident hematuria and renal functional deterioration ( 6 ) .
ncs should be considered in the differential diagnosis of patients with unknown cause of hematuria and flank pain . in conjunction with an appropriate clinical history ,
ct findings indicating decreased aortomesenteric angle and a shortened aortomesenteric distance can suggest the diagnosis for both conditions .
 introduction : superior mesenteric artery syndrome is an uncommon cause of duodenal obstruction , and its manifestations are generally associated with compression on the third part of the duodenum between the abdominal aorta and superior mesenteric artery.case presentation : in this report , a patient is described presenting with epigastric pain and weight loss due to superior mesenteric artery syndrome . 
 the patient has also nutcracker syndrome , which is the compression of the left renal vein between the aorta and the superior mesenteric artery at its origin.conclusions:in addition to an appropriate clinical history , ct findings indicating decreased aortomesenteric angle and a shortened aortomesenteric distance can suggest the diagnosis for both the superior mesenteric artery syndrome and accompanying nutcracker syndrome . 
Introduction:
Case Presentation:
Conclusions:
1. Introduction
2. Case Presentation
3. Discussion