Macroscopic Hematuria in Adolescents - Two Cases of Nutcracker Syndrome

Macroscopic hematuria is a common cause of referral to the Pediatric Emergency Department and can be due to a variety of etiologies, which can be identified through detailed clinical history and physical examination.Nonetheless, rare causes may go unnoticed with the most used diagnostic exams.Nutcracker syndrome describes left renal vein compression between the superior mesenteric artery and the abdominal aorta or between the abdominal aorta and vertebral column.The majority of the patients are asymptomatic, and when symptomatic, clinical manifestations include variable combinations of hematuria, proteinuria, left flank or abdominal pain.Diagnosis is usually made after the exclusion of other causes responsible for the symptoms, and it is confirmed on imaging results.Treatment remains controversial, with pediatric patients being typically managed conservatively due to spontaneous resolution in most cases.With these two cases, the authors aim to bring awareness to this entity so it can be easily identified and avoid unnecessary diagnostic workup.