Left Ovarian Venous Dilatation in Patients who Underwent Cardiac Surgery

Objective: Compression of gonadal venous return results in left ovarian venous dilatation, which can cause pelvic congestion syndrome-related symptoms such as dysmenorrhea and metrorrhagia. Left renal vein compression and left ovarian vein compression are associated with a narrowed aortomesenteric angle, and a low body mass index is associated with left renal vein compression. This study aimed to assess physical characteristics and left ovarian venous dilatation in patients who underwent cardiac surgery. Methods: Among 164 patients who underwent cardiac surgery at our hospital in 2018, there were 43 female patients (26%). Left ovarian venous dilatation was diagnosed using preoperative plain computed tomography. We assessed their physical characteristics, clinical features, and outcomes, and image findings, including aortomesenteric distance and angle. Results: Among the 43 female patients, three showed left ovarian venous dilatation. No symptoms related to compression of gonadal venous return were observed in the female patients. Patients with left ovarian venous dilatation showed significantly reduced aortomesenteric distance. Their body mass index was significantly low. Conclusion: Leptosome females with low body mass index can develop reduced aortomesenteric distance resulting in left ovarian venous dilatation, although it is not always directly related to the appearance of symptoms. Pelvic congestion syndrome should be considered in leptosome female patients planning to undergo cardiac surgery.

Definite Cutoff Point to Diagnose “Nutcracker Syndrome”: An Ignored Cause of Microscopic Hematuria

Background: One of the causes of gross hematuria is nutcracker syndrome or renal vein entrapment. The computerized tomography (CT) scan can demonstrate the precise left renal vein (LRV) compression between the aorta and the superior mesenteric artery. These modalities are usually applied for initial investigations. At present, there is no definite cutoff point to diagnose nutcracker syndrome in patients who present with asymptomatic microscopic hematuria (AMH). Objective: To study whether the nutcracker syndrome might be associated with AMH and to determine the definite cutoff point to diagnose nutcracker syndrome. Materials and Methods: The authors retrospectively reviewed the CT scans of patients diagnosed with AMH and had no abnormal urological findings from standard investigations compared with patients in a control group who had normal urine exams and no urological abnormalities from CT scans. CT scan assessment included the diameter ratio of the LRV at the aortomesenteric angle and the renal hilar, the aortomesenteric distance, and the aortomesenteric angle. Results: Forty-eight patients diagnosed with AMH were included in the present study. The diameter ratio of the LRV at the aortomesenteric angle and the renal hilar in the AMH group was 0.7 compared to 0.9 for the control group (p=0.001). The mean aortomesenteric angle in patients with AMH was 45.9 degrees compared to 54.8 degrees in the control group (p=0.004). The mean aortomesenteric distance in patients with AMH was 1.36 cm compared to 1.56 cm in the control group (p=0.032). Conclusion: These data showed the significant difference in the diameter ratio of the LRV at the aortomesenteric angle and the renal hilar, the aortomesenteric angle, and the aortomesenteric distance between patients with AMH and the normal population. Therefore, the nutcracker syndrome may be associated with AMH. Keywords: Microscopic hematuria, Nutcracker, Left renal vein

Angulation and Distance of Superior Mesenteric Artery According to Body Mass Index on Patients Based on Computed Tomography Scan Study at Chitwan Medical College

Background: Superior mesenteric artery syndrome is a rare but vital cause of upper gastrointestinal obstruction which occurs when the third portion of the duodenum is trapped between aorta and superior mesenteric artery. The sig­nificant decrease of the angle and distance between the superior mesenteric artery and aorta is the etiology of Superior mesenteric artery syndrome.The study aimed to identify the angulations and distance of superior mesenteric artery from aorta and their correlation with body mass index in patients re­ferred for contrast enhanced computed tomography of abdomen examination in Chitwan Medical College. Methods: The angle between the aorta and superior mesenteric artery was measured in arterial phase of the abdominal scan in the multiplanar recon­structed image in sagittal plane. The distance between the superior mesen­teric artery and aorta was measured in axial plane at the level of 3rd part of duodenum. Results: The aortomesenteric distance was obtained to be 13.30 ± 4.75 mm and the aortomesenteric angle was obtained to be 54.7±16.91 degree for a to­tal of 210 patients. There was a positive correlation between body mass index and aortomesenteric distance (p=0.086) and significant positive correlation between body mass index and aortomesenteric angle (p=0.122). Additionally, it showed there was significant positive correlation between aortomesenteric angle and aortomesenteric distance. Conclusions: The distance and angle between the superior mesenteric artery and the aorta correlates significantly with the body mass index which indicates that the decrease in body mass index can be used as a risk factor of superior mesenteric artery syndrome.

Superior Mesenteric Artery Syndrome: Clinical, Endoscopic, and Radiological Findings

Background. The superior mesenteric artery (SMA) syndrome is a rare entity presenting with upper gastrointestinal tract obstruction and weight loss. Studies to determine the optimal methods of diagnosis and treatment are required. Aims and Methods. This study aims at analyzing the clinical presentation, diagnosis, and management of SMA syndrome. Ten cases of SMA syndrome out of 2074 esophagogastroduodenoscopies were suspected. A contrast-enhanced computed tomography (CECT) scan was performed to confirm the diagnosis. After, a gastroenterologist and a nutritionist personalized the therapy. Furthermore, we compared the demographical, clinical, endoscopic, and radiological parameters of these cases with a control group consisting of 10 cases out of 2380 EGDS of initially suspected (but not radiologically confirmed) SMA over a follow-up 2-year period (2015-2016). Results. The prevalence of SMA syndrome was 0.005%. Median age and body mass index were 23.5 years and 21.5 kg/m2, respectively. Symptoms developed between 6 and 24 months. Median aortomesenteric angle and aorta-SMA distance were 22 and 6 mm, respectively. All patients improved on conservative treatment. In our series, a marked (>5 kg) weight loss (p=0.006) and a long-standing presentation (more than six months in 80% of patients) (p=0.002) are significantly related to a diagnosis of confirmed SMA syndrome at CECT after an endoscopic suspicion. A “resembling postprandial distress syndrome dyspepsia” presentation may be helpful to the endoscopist in suspecting a latent SMA syndrome (p=0.02). The narrowing of both the aortomesenteric angle (p=0.001) and the aortomesenteric distance (p<0.001) was significantly associated with the diagnosis of SMA after an endoscopic suspicion; however, the narrowing of the aortomesenteric distance seemed to be more accurate, rather than the narrowing of the aortomesenteric angle. Conclusion. SMA syndrome represents a diagnostic and therapeutic challenge. Our results show the following findings: the importance of the endoscopic suspicion of SMA syndrome; the preponderance of a long-standing and chronic onset; a female preponderance; the importance of the nutritional counseling for the treatment; no need of surgical intervention; and better diagnostic accuracy of the narrowing of the aorta-SMA distance. Larger prospective studies are needed to clarify the best diagnosis and management of the SMA syndrome.