SHM Converge Scientific Abstract ePoster Gallery-Not So Normal Case of Abdominal Pain

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This case highlights median arcuate ligament syndrome (MALS), a rare cause of abdominal symptoms due to compression of the celiac artery and/or surrounding ganglion plexus by the median arcuate ligament. Because symptoms are nonspecific, diagnosis is often delayed and requires a high index of suspicion.<br /><br />The patient was a 54-year-old man with alcoholic cirrhosis and type 2 diabetes who was admitted for recurrent syncope and one episode of bright red blood per rectum. Initial workup for syncope and hypoxia was unrevealing: telemetry, EEG, echocardiography, TSH, troponin, and EKG were normal aside from sinus tachycardia. Chest CTA showed bibasilar infiltrates consistent with aspiration, and his hypoxia improved with antibiotics and supportive care.<br /><br />During the hospitalization, abdominal imaging suggested MALS. A CT mesenteric ischemia protocol demonstrated marked stenosis and a characteristic “hooked” appearance of the proximal celiac trunk from median arcuate ligament compression. Follow-up CTA with provocative maneuvers further confirmed near-complete occlusion of the proximal celiac artery during expiration, with improvement during inspiration. Duplex ultrasound could not visualize the celiac artery.<br /><br />MALS typically causes postprandial epigastric pain, bloating, nausea, vomiting, and unintentional weight loss. It is a diagnosis of exclusion. Confirmation relies on imaging such as duplex ultrasound, CT angiography, MR angiography, or catheter angiography, often with respiratory maneuvers.<br /><br />Treatment options include open surgical decompression with or without reconstruction, or laparoscopic/robotic median arcuate ligament release with or without ganglionectomy. Persistent or residual symptoms may be treated with angioplasty or stenting, and bypass surgery may be considered in select cases. The patient was awaiting vascular surgery evaluation for possible intervention.

Asset Subtitle

Ann M. Kumfer

Meta Tag

Author List Ann M. Kumfer, Evan Raff, Lauren Raff

Category Clinical Vignettes

Concept Median Arcuate Ligament Syndrome

Concept Celiac Artery Narrowing

Concept Surgical Median Arcuate Ligament Release

Concept Diagnosis of Exclusion

Concept Epigastric Pain

Distinguished Non-Finalist

Presenter Organization University of North Carolina Hospital

Presenting Author Ann M. Kumfer

Track Adult

Keywords

median arcuate ligament syndrome

MALS

celiac artery compression

abdominal symptoms

hooked celiac trunk

CT angiography

duplex ultrasound

respiratory maneuvers

surgical decompression

vascular surgery

Median Arcuate Ligament Syndrome

Celiac Artery Narrowing

Surgical Median Arcuate Ligament Release

Diagnosis of Exclusion

Epigastric Pain