An 18-year-old poorly built ( BMI = 17 kg / sq m ) female patient with complaints of chronic intermittent postprandial epigastric pain and occasional episodes of vomiting with normal routine lab investigations and no previous comorbidities.
Contrast CT abdomen showed a characteristic hooked appearance with focal narrowing of the proximal celiac axis and post stenotic dilatation in sagittal plane ( fig 1 ) suggestive of median arcuate ligament syndrome (MALS)
Aorto-mesenteric angle (AMA) measured 19.5° (Fig. 2)and aortomesenteric distance ( AMD ) was 7.35 mm (Fig. 3 ). Dilatation of the proximal portion of 3rd part of duodenum with reduced AMA and AMD was suggestive of Wilkie’s syndrome.
Characteristic beak sign with abrupt narrowing of the left renal vein (LRV) between the aorta and superior mesenteric artery (SMA), with proximal dilatation of the LRV, was seen (Fig. 4). Reduced AMA measuring 19.5 °, LRV diameter ratio of 5.6 (ratio of diameter of LRV at hilum to the diameter at aortomesenteric region) (Fig. 5) and increased beak angle measuring 40.6° (Fig. 6) was obtained suggestive of nutcracker phenomenon.
Abdominal vascular compression syndromes can either be compression of vascular structures or compression of abdominal viscera by vascular structures. Median arcuate ligament syndrome (MALS), Wilkie’s syndrome and nutcracker phenomenon occurring concurrently in the same patient is extremely rare  Marked weight loss, low body mass index (BMI ), post hip/body spica cast and post scoliosis surgical status are known risk factors , , 
MALS is a rare abdominal vascular compression syndrome in which there is an indentation on the celiac axis by a low lying fibrous arch called median arcuate ligament which unites the diaphragmatic crura on either side of the aortic hiatus. In the sagittal plane, a characteristic hooked appearance with focal narrowing of the proximal celiac axis visible on inspiratory CT angiogram is the diagnostic finding. It is associated with post stenotic dilatation or collateral vessel formation from the branches of SMA. 
Wilkie's syndrome (also known as SMA syndrome/aortomesenteric duodenal compression syndrome) is caused by compression of the third part of the duodenum between the SMA and aorta as a result of loss of adipose tissue between them. The diagnostic findings include
The normal AMD is typically between 10 and 34 mm and is measured at the level of the duodenum as it travels between the aorta and SMA, and the normal AMA is between 28-65 ° 
Nutcracker phenomenon refers to compression of left renal vein (LRV) between SMA and aorta (anterior nutcracker) or between aorta and vertebral body (posterior nutcracker ) with no clinical symptoms. Symptoms like haematuria, flank pain, varicocele, orthostatic proteinuria and orthostatic intolerance with relevant radiological findings are called nutcracker syndrome. This condition can lead to renal venous hypertension with left renal vein thrombosis and eventual formation of pelvic varices.  CT findings include
The initial management for all 3 conditions mentioned above is conservative by insertion of a nasogastric tube, and by enteral feeding for restoration of the aortomesenteric fatty tissue. . For the treatment of Wilkie’s syndrome, lying in right decubitus position and postural corrections like Hayes manoeuvre in which pressure is applied below the umbilicus in a cephalic and dorsal direction and thereby relaxing the small bowel mesentery can be used to relieve duodenal compression. 
 Oh MJ. Superior Mesenteric Artery Syndrome Combined with Renal Nutcracker Syndrome in a Young Male: A Case Report [published correction appears in Korean J Gastroenterol. 2017 Dec 25;70(6):312]. Korean J Gastroenterol. 2017;70(5):253‐260. doi:10.4166/kjg.2017.70.5.253
 Bhagirath Desai A, Sandeep Shah D, Jagat Bhatt C, Umesh Vaishnav K, Salvi B. Measurement of the Distance and Angle Between the Aorta and Superior Mesenteric Artery on CT Scan: Values in Indian Population in Different BMI Categories. Indian J Surg. 2015 Dec;77(Suppl 2):614-7. doi: 10.1007/s12262-013-0941-1. Epub 2013 Jul 14. PMID: 26730074; PMCID: PMC4692896.
 Zhu ZZ, Qiu Y. Superior mesenteric artery syndrome following scoliosis surgery: its risk indicators and treatment strategy. World J Gastroenterol 2005; 11:3307–3310
 Hughes JP, McEntire JE, Setze TK. Cast syndrome: duodenal dilation or obstruction in a patient in a body cast, with review of the literature. Arch Surg 1974;108(2):230–232
 Horton KM, Talamini MA, Fishman EK. Median arcuate ligament syndrome: evaluation with CT angiography. RadioGraphics 2005; 25:1177–1182
 Unal B, Aktas A, Kemal G, et al. Superior mesenteric artery syndrome: CT and ultrasonography findings. Diagn Interv Radiol 2005; 11:90–95
 Lamba R, Tanner DT, Sekhon S, McGahan JP, Corwin MT, Lall CG. Multidetector CT of vascular compression syndromes in the abdomen and pelvis [published correction appears in Radiographics. 2015 May-Jun;35(3):973]. Radiographics. 2014;34(1):93‐115. doi:10.1148/rg.341125010
 Stewart BH, Reiman G. Left renal venous hypertension "nutcracker" syndrome. Managed by direct renocaval reimplantation. Urology. 1982;20(4):365‐369. doi:10.1016/0090-4295(82)90457-5
 Rudloff U, Holmes RJ, Prem JT, Faust GR, Moldwin R, Siegel D. Mesoaortic compression of the left renal vein (nutcracker syndrome): case reports and review of the literature. Ann Vasc Surg. 2006;20(1):120-129. doi:10.1007/s10016-005-5016-8
 Fong, J., Poh, A., Tan, A., & Taneja, R. (2014). Imaging Findings and Clinical Features of Abdominal Vascular Compression Syndromes. American Journal Of Roentgenology, 203(1), 29-36. doi: 10.2214/ajr.13.11598
 Kim KW, Cho JY, Kim SH, et al. Diagnostic value of computed tomographic findings of nutcracker syndrome: correlation with renal venography and renocaval pressure gradients. Eur J Radiol 2011; 80:648–654
 Richardson WS, Surowiec WJ. Laparoscopic repair of superior mesenteric artery syndrome. Am J Surg. 2001;181(4):377‐378. doi:10.1016/s0002-9610(01)00571-2
 Mandarry MT, Zhao L, Zhang C, Wei ZQ: A comprehensive review of superior mesenteric artery syndrome. Eur Surg. 2010, 42:229-236. 10.1007/s10353-010-0561-y
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.