Somatic symptom disorder (SSD) is a diagnosis that was introduced with publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013. It eliminated the diagnoses of somatisation disorder, undifferentiated somatoform disorder, hypochondriasis and pain disorder; most of the patients who previously received these diagnoses are now diagnosed in DSM-5 with SSD. The main feature of this disorder is a patient’s concern with physical symptoms for which no biological cause is found. It requires psychiatric assessment to exclude comorbid psychiatric disease. Failure to recognise this disorder may lead the unwary physician or surgeon to embark on investigations or diagnostic procedures which may result in iatrogenic complications. It also poses a significant financial burden on the healthcare service. Patients with non-specific abdominal pain have a poor symptomatic prognosis with continuing use of medical services. Proven treatments include cognitive behavioural therapy, mindfulness therapy and pharmacological treatment using selective serotonin reuptake inhibitors or tricyclic antidepressants. The authors describe the case of a 31-year-old woman with an emotionally unstable personality disorder and comorbid disease presenting to the emergency department with a 3-week history of left-sided abdominal and leg pain. Despite a plethora of investigations, no organic cause for her pain was found. She was reviewed by the multidisciplinary team including surgeons, physicians, neurologists and psychiatrists. A diagnosis of somatoform symptom disorder was subsequently rendered. As patients with SSD will present to general practice and the emergency department rather than psychiatric settings, this case provides a cautionary reminder of furthering the need for appropriate recognition of this condition.

Nutcracker syndrome (NCS) is a rare vascular compression disorder that involves compression of the left renal vein most commonly between the aorta and the superior mesenteric artery (SMA), although variations exist. It is associated with the formation of the left renal vein from the aortic collar during the 6th–8th week of gestation and abnormal angulation of the SMA from the aorta. Collateralisation of venous circulation including mainly the left gonadal vein and the communicating lumbar vein are the most significant effects. It has a female predilection occurring in the third to fourth decade and it tends to be diagnosed earlier in men. Affected individuals may present with a myriad of symptoms such as haematuria, left flank pain and proteinuria. As patients often present with these non-specific symptoms to primary care, knowledge of NCS is essential. The diagnosis can be rendered with Doppler ultrasonography, retrograde venography, CT angiography, intravascular ultrasound and magnetic resonance angiography. The authors describe the case of a 39-year-old woman with a low body mass index (BMI) presenting with generalised abdominal and flank pain as well as chronic microcytic anaemia. Physical examination findings were suggestive of biliary or renal colic. Laboratory investigations confirmed her anaemia (haemoglobin 88 g/L, mean corpuscular volume (MCV) 72 fL), but were otherwise unremarkable. Urinalysis showed proteinuria and haematuria. However, ultrasonography was unremarkable with a normal gallbladder and no evidence of calculi. Her CT scan showed marked compression of the left renal vein between the aorta and the SMA (nutcracker phenomenon), with upstream left renal, left gonadal and left lumbar vein dilatation. She was managed conservatively. This paper provides an overview of the aetiology, embryology, clinical manifestations, imaging modalities and management of NCS.