Triple Trouble of Upper Gastrointestinal Tract: A Rare Case Report of Pyloric Stricture with Dunbar Syndrome (Median Arcuate Ligament Syndrome) and Nutcracker Phenomenon

This case report presents a rare coexistence of three conditions in a 38-year-old male: pyloric stricture, Dunbar syndrome (median arcuate ligament syndrome), and the nutcracker phenomenon. The patient presented with persistent vomiting and abdominal pain for 3 months. Upper gastrointestinal (GI) endoscopy revealed food stasis in the stomach and a Forrest Grade III prepyloric ulcer with a tight pyloric stricture beyond which the scope could not be passed – features consistent with gastric outlet obstruction (GOO). A biopsy of the prepyloric ulcer confirmed acute gastritis with Helicobacter pylori infection. Further evaluation with contrast-enhanced computed tomography (CT) of the abdomen demonstrated a benign pyloric stricture with GOO, compression of the left renal vein by the superior mesenteric artery consistent with the nutcracker phenomenon, and narrowing of the celiac artery origin suggestive of Dunbar syndrome. These findings were confirmed on CT abdominal angiography. Despite receiving standard H. pylori eradication therapy, the patient’s symptoms persisted. He subsequently underwent antrectomy with gastrojejunostomy, leading to complete resolution of symptoms. He remains asymptomatic on regular follow-up. This report underscores the importance of actively evaluating patients with refractory upper GI symptoms for overlapping structural and vascular abnormalities. It demonstrates that pyloric stricture can coexist with vascular compression syndromes such as Dunbar syndrome and the nutcracker phenomenon. Recognizing these combined conditions is crucial for accurate diagnosis and timely treatment.