Expanding the Clinical Spectrum of Pediatric Nutcracker Syndrome: A Case of Nonrenal Presentation

ABSTRACT: Nutcracker syndrome (NCS) is an uncommon vascular compression disorder resulting from entrapment of the left renal vein (LRV), most often between the superior mesenteric artery and the abdominal aorta. Although it is well described in adults, the condition remains underdiagnosed in children because of its nonspecific and variable clinical manifestations. We report the case of a 15-year-old adolescent girl presented with recurrent epigastric abdominal pain, nonbilious vomiting, retrosternal chest pain, and severe dysmenorrhea, without hematuria or flank pain. Initial laboratory investigations, urinalysis, and cardiac evaluation are unremarkable. Ultrasonography visualized the head of the pancreas as appearing mildly heterogeneous. Upper gastrointestinal endoscopy showed nonspecific gastropathy. Contrast-enhanced computed tomography of the abdomen and pelvis demonstrated a markedly reduced aortomesentric angle with compression of LRV, consistent with anterior nutcracker. The patient was managed conservatively with dietary modification and symptomatic therapy, resulting in significant clinical improvement. This case highlights the importance of considering NCS in adolescents presenting with unexplained abdominal or chest pain and emphasises the role of appropriate imaging in diagnosis. Conservative management remains the preferred approach in pediatric patients owing to the high likelihood of spontaneous resolution with growth and weight gain.