Chronic abdominal pain and haematuria in internal medicine: do not forget about the Nutcracker syndrome
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IM - PHYSICAL EXAMINATION
Chronic abdominal pain and haematuria in internal medicine: do not forget about the Nutcracker syndrome Lorenzo Falsetti1 · Giuseppe Pio Martino2 · Massimo Mattioli3 · Saverio Menetti4 · Carla Serra5 Received: 7 April 2020 / Accepted: 27 June 2020 © Società Italiana di Medicina Interna (SIMI) 2020
Keywords Focused ultrasound · Nutcracker syndrome · Left renal vein entrapment
Physical examination A 54-year-old woman was referred to our internal medicine department because of chronic abdominal pain and microscopic haematuria. She complained of a mild, tolerable but persistent low abdominal and pelvic pain, which did not have any relationship with food intake, body position or bowel function. Such symptoms started when she was 20, but previous clinical and diagnostic evaluations resulted inconclusive despite the several diagnoses hypothesized and tested (irritable bowel disease, diverticular disease, urinary tract infections, pelvic inflammatory disease and conversion disorder). All the attempted treatments (among which, protonpump inhibitors and antidepressant drugs) did not translate into a significant clinical improvement. After several years, low back pain with inflammatory features and lumbar spine stiffness appeared. Blood tests showed CRP and ESR increase. Rheumatoid factor, anti-citrullinated-peptide and antinuclear antibodies were negative, HLA-B27 antigen was positive. A lumbo-sacral spine X-ray suggested bilateral sacro-ileitis, allowing to put a diagnosis of ankylosing spondylitis. NSAIDs were used as first-line agents for about 1 * Lorenzo Falsetti [email protected] 1
Internal and Sub‑Intensive Medicine Department, Azienda Ospedaliero-Universitaria “Ospedali Riuniti”di Ancona, Via Conca 10, Ancona, Italy
2
Internal Medicine Department, Ospedale Murri di Fermo, Fermo, Italy
3
UOC Emergency Department, Azienda Ospedaliera “Ospedali Riuniti Marche Nord”, Pesaro, Italy
4
Internal Medicine, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
5
Department of Organ Failure and Transplantation, Ultrasound Unit, S.Orsola-Malpighi Hospital, Bologna, Italy
year but subsequently, for the worsening of articular symptoms, TNF-α antagonists were started. Such a diagnosis could have explained abdominal pain and haematuria, however, during the following 9 years, abdominal pain and microscopic haematuria persisted. In the suspect of a chronic inflammatory bowel disease, she underwent to multiple endoscopic examinations: gastroscopies revealed chronic helicobacter pylori-negative gastritis, while colonoscopies did not show any abnormality. Fifteen abdominal ultrasound examinations, annual gynaecological visits, six urine coltures and periodic autoantibodies determination resulted normal. In the days before our evaluation, the gastroenterologist suggested symptomatic therapy for a suspect irritable bowel disease and, to better investigate the chronic haematuria, the nephrologist recommended a renal biopsy, which the patient refused. When admitted to our department
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