J Gastrointestin Liver Dis, September 2019 Vol. 28 No 3: 262 Vanishing Splenic Cyst - Visible on Ultrasound but Non-Detected on MRI Cosmin Caraiani 1 , Timothy Kurniawan 2 , Renata Vasilache 2 , Ciprian Brisc 2 1) Department of Medical Imaging, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca; 2) Department of Gastroenterology, University of Medicine and Pharmacy, Oradea, Romania IMAGE OF THE ISSUE DOI: http://dx.doi.org/10.15403/jgld-208 A 21-year old female patient was referred for postprandial nausea and vomiting, early satiety and epigastric fullness. No incidents were noted in her medical history. Abdominal ultrasonography (US) detected two cystic lesions in the lef hypochondrium, measuring 57 mm and 12 mm (Fig. 1). Te inhomogeneous aspect of the larger lesion raised the suspicion of a complicated splenic cyst. On magnetic resonance imaging (MRI) a single cystic lesion of the spleen was detected, approximately 14 mm in size, located on the anterior surface of the spleen (Fig. 2). Te lesion had homogenous content, thin and smooth walls, being interpreted as a primary splenic cyst. A neoplastic or infectious origin of the cyst was excluded. Incidentally, MRI found a dilated lef renal vein, compressed between the aorta and the superior mesenteric artery (SMA) (Fig. 3, white arrow). Te distance between the aorta and the SMA was 5mm (Fig. 3, gray arrow), lower than normal (between 10 and 28mm). Due to the discordant results of US and MRI, we repeated the US, this time performed by a more experienced ultrasonographer. Afer water ingestion, the larger cystic lesion in the lef hypochondrium proved to be the dilated stomach. Real time hydrosonography proved also a dilated duodenum that tapered near the SMA. Based on all these fndings, the diagnosis of aorto-mesenteric compression syndrome (Wilkie’s syndrome) was made. Aorto-mesenteric compression syndrome is a rare acquired disease, in which acute angulation of the SMA leads to duodenal obstruction [1]. Te patient may present with chronic, insidious symptoms [2]. Tis pathology is suspected on imaging studies when tapering of the third part of the duodenum near the SMA is seen or when the distance between the aorta and the SMA is smaller than 8 mm and the angle between the aorta and the SMA is acute, with values lower than 15° [3-4]. Tis pathology is associated with the nutcracker syndrome (compression of the lef renal vein between the aorta and the SMA), when abdominal lef fank pain and hematuria might be present [5]. Corresponding author: Cosmin Caraiani, ccaraiani@yahoo.com Conficts of interest: None to declare. REFERENCES 1. Roy A, Gisel JJ, Roy V, Bouras EP. Superior mesenteric artery (Wilkie’s) syndrome as a result of cardiac cachexia. J Gen Intern Med 2005;20:C3-C4. 2. Lippl F, Hannig C, Weiss W, Allescher HD, Classen M, Kurjak M. Superior mesenteric artery syndrome: diagnosis and treatment from the gastroenterologist’s view. J Gastroenterol 2002;37:640–643. doi:10.1007/ s005350200101 3. Gustafsson L, Falk A, Lukes PJ, Gamklou R. Diagnosis and treatment of superior mesenteric artery syndrome. Br J Surg 1984;71:499–501. doi:10.1002/bjs.1800710706 4. Hines JR, Gore RM, Ballantyne GH. Superior mesenteric artery syndrome. Diagnostic criteria and therapeutic approaches. Am J Surg 1984;148:630–632. doi:10.1016/0002-9610(84)90339-8 5. Waseem M, Upadhyay R, Prosper G. Te nutcracker syndrome: an underrecognized cause of hematuria. Eur J Pediatr 2012;171:1269–1271. doi:10.1007/s00431-012-1761-1