Le syndrome casse-noisette (Nutcracker) : une cause rare d’hématurie

Nutcracker syndrome: A rare cause of chronic pelvic pain and left back pain

The Nutcracker Syndrome is a rare and often unrecognized cause of chronic pelvic pain and left back pain. These symptoms are due to the left renal vein compression between the aorta and the superior mesenteric artery (anterior nutcracker) or between the aorta and the spine (posterior nutcracker). The variety of clinical manifestations make the diagnosis difficult and commonly delayed. Therefore, imaging plays a key role in correcting the diagnosis by confirming the left renal vein stenosis and ruling out any differential diagnosis. Treatment options are discussed by a multidisciplinary team involving urologists, nephrologists and vascular surgeons for each patient. We report the case of 2 patients presenting chronic pelvic and lower back pain in whom clinical investigation and CT imaging findings were consistent with a nutcracker syndrome.

ACR Appropriateness Criteria® Hematuria-Child

Hematuria is the presence of red blood cells in the urine, either visible to the eye (macroscopic hematuria) or as viewed under the microscope (microscopic hematuria). The clinical evaluation of children and adolescents with any form of hematuria begins with a meticulous history and thorough evaluation of the urine. The need for imaging evaluation depends on the clinical scenario in which hematuria presents, including the suspected etiology. Ultrasound and CT are the most common imaging methods used to assess hematuria in children, although other imaging modalities may be appropriate in certain instances. This review focuses on the following clinical variations of childhood hematuria: isolated hematuria (nonpainful, nontraumatic, and microscopic versus macroscopic), painful hematuria (ie, suspected nephrolithiasis or urolithiasis), and renal trauma with hematuria (microscopic versus macroscopic). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Micro- and macroscopic hematuria caused by renal vein entrapment: systematic review of the literature

BACKGROUND

Hematuria secondary to renal vein entrapment is mentioned only passing in textbooks and reviews.

METHODS

We performed a search of the National Library of Medicine database for peer-reviewed publications using the terms "renal vein" or "nutcracker" and "hematuria".

RESULTS

We identified 187 published reports/studies that covered 736 patients, of whom 288 had microscopic hematuria and 448 had macroscopic hematuria. The patient cohort comprised 159 patients aged ≤17 years. Abdominal pain was absent in  approximately 65% of all patients, and a clinically relevant left-sided varicocele was observed in 29% of the male patients. A normal pre-aortic left renal vein and an anomalous anatomy were noted in 680 and 56 patients, respectively. The body mass index (BMI) was lower in patients with renal vein entrapment than in the controls, with a regression of hematuria correlating with an increase in BMI. A surgical procedure was attempted in 34% of the patients, of which the most common were endovascular stenting and transposition of the renal vein distally into the vena cava.

CONCLUSIONS

In cases of unexplained hematuria with or without abdominal pain, clinicians should consider the diagnosis of renal vein congestion, especially in males with varicocele. Ultrasonic Doppler flow scanning is the recommended initial diagnostic modality in these patients. Expectation management is advised in the great majority of cases.