Vascular compression syndromes are disorders in which adjacent anatomical structures compress blood vessels, impairing arterial flow or venous drainage. Superior mesenteric artery (SMA) syndrome causes duodenal obstruction due to a reduced aortomesenteric angle and distance. Nutcracker syndrome (NCS) occurs when the left renal vein (LRV) is compressed between the SMA and aorta. Although individually rare, concurrent SMA syndrome and NCS are reported only in limited cases, with prevalence estimates of 0.1–0.3% and 0.6–3%, respectively, contributing to nonspecific symptoms, diagnostic delay, and increased morbidity. We report a 42-year-old female presenting with two months of chronic abdominal pain with acute worsening, associated with early satiety, nausea, diarrhea, and a 10-pound unintentional weight loss. Physical examination demonstrated left-sided abdominal tenderness, while laboratory findings were largely unremarkable. Initial evaluation, including an upper gastrointestinal series and gastric emptying study, did not demonstrate obstruction or delayed transit, prompting further investigation. Symptoms partially improved with dietary modification but recurred with normal oral intake, suggesting a structural rather than purely functional etiology. Computed tomography (CT) demonstrated a reduced aortomesenteric angle of 28° and distance of 3.5 mm with duodenal narrowing. Imaging also showed greater than 50% compression of the LRV, dilation of the gonadal veins, and pelvic varices, findings consistent with concurrent SMA syndrome and NCS. The patient was counseled on conservative management options, including weight gain and nutritional rehabilitation, as well as surgical interventions when conservative therapy fails, such as duodenojejunostomy or renal vein procedures. Close follow-up was recommended to evaluate response to therapy and determine the need for operative management. This case highlights the importance of maintaining clinical suspicion for vascular compression syndromes and demonstrates the diagnostic value of advanced imaging when routine testing is inconclusive.
