Median arcuate ligament syndrome diagnosis on Computed Tomography: what a radiologist needs to know

A rare case of median arcuate ligament syndrome presenting with chronic abdominal pain managed surgically: A case report

The disorder median arcuate ligament syndrome (MALS) develops when the median arcuate ligament compresses the celiac artery and accompanying nerve fibers leading to postprandial abdominal pain, nausea and bloating symptoms that are commonly mistaken for other gastrointestinal or vascular conditions. A 29-year-old female patient experienced right hypochondrium pain after eating combined with burning stomach pain and debilitating bloating episodes for 5 months. Computed tomography (CT) angiography scan and Doppler ultrasonography revealed celiac artery stenosis due to pressure from the median arcuate ligament along with cholelithiasis. The patient's vague symptoms illustrate the diagnostic difficulty of MALS patients who also have cholelithiasis and demonstrates how CT and Doppler ultrasonography serve crucially to validate MALS diagnosis. Surgical treatment of the median arcuate ligament by physical release has proved successful in treating symptoms despite patients also having cholelithiasis. Early detection and surgical treatment can increase favorable outcomes for patients with such rare conditions.

Median arcuate ligament syndrome in a 51-year-old-male: A rare case report

INTRODUCTION

Median arcuate ligament syndrome is an uncommon vascular compression syndrome caused by the diaphragmatic crura and the median arcuate ligament compressing the celiac artery. It has an incidence of 2 cases per 100,000 population.

CASE PRESENTATION

A 51-year-old male presented with postprandial abdomen pain for the previous ten years. Computer tomography (CT) angiogram of the abdomen with CT abdomen and pelvis was performed which clearly shows focal narrowing at the origin of the celiac artery with distal collateral reformations consistent with MALS. The patient was diagnosed with MALS and scheduled for laparoscopic division of the median arcuate ligament. The division of median arcuate ligament was performed carefully after visualizing the compression made by the median arcuate ligament on the celiac trunk.

DISCUSSION

Diagnosis of MALS may be difficult due to nonspecific clinical presentation. Imaging helps to visualize celiac trunk compression and is essential in verifying the diagnosis of MALS. Surgical decompression of the celiac artery is the definite treatment.

CONCLUSION

Median arcuate ligament syndrome is a rare entity with ambiguous clinical presentation with surgery as the mainstay of treatment.

Chronic Abdominal Pain in Median Arcuate Ligament Syndrome: A Diagnostic and Therapeutic Challenge

Median arcuate ligament syndrome is a rare and difficult-to-diagnose condition that typically presents with nonspecific symptoms of abdominal pain, nausea, and vomiting. The condition is caused by compression of the celiac artery by the median arcuate ligament at the level of the diaphragmatic aortic hiatus. In this case report, we present a 25-year-old male who presented with a chief complaint of persistent abdominal pain, nausea, and vomiting. The patient's symptoms, computed tomography imaging, and abdominal Doppler ultrasound results were consistent with the classical presentation of the disease. The patient's symptoms definitively resolved after laparoscopic median arcuate ligament decompression.

Chronic Post-Prandial Epigastric Pain Associated with Median Arcuate Ligament Syndrome and Atherosclerosis of the Celiac Trunk in An Elderly Woman: A Case Report

BACKGROUND Post-prandial abdominal pain due to bowel ischemia can be caused by stenosis (atherosclerosis) or by compression of the arteries of the celiac axis. Median arcuate ligament syndrome (MALS) results from compression at the origin of the celiac trunk by the arcuate ligament. This report describes a 66-year-old woman with chronic post-prandial epigastric pain associated with atherosclerosis of the celiac trunk, managed with angioplasty and stenting combined with MALS. CASE REPORT A 66-year-old female patient with a history of dyslipidemia presented with chronic epigastric pain with post-prandial episodes for 4 years. Two years before the admission, her pain increased with meals and was not relieved by empirical treatment for gastritis. An esophagogastroduodenoscopy and colonoscopy showed chronic gastritis. One year later, a resection of the gastric submucosal tumor was performed, without improving her symptoms. In this presentation, the prompt computed tomography revealed hook-shaped stenosis of the celiac trunk and mild post-stenosis dilatation, highly suggestive of MALS. However, the patient refused to undergo surgery despite the benefit of this intervention. Concurrently, moderately severe atherosclerosis of the celiac trunk was detected during intra-vessel imaging. The patient was treated individually and underwent angioplasty with stenting. At a 5-month follow-up, the patient's condition was stable and she had no gastrointestinal symptoms. CONCLUSIONS Due to the low prevalence and nonspecific symptoms of MALS, physicians should be highly suspicious of this disease, especially in patients with post-prandial abdominal pain. Angioplasty and stenting can be performed in selected patients with MALS and atherosclerosis of the celiac trunk.

Under pressure: a head-to-toe review of vascular compression syndromes

Vascular compression syndromes are a group of conditions resulting from mechanical compression of blood vessels by adjacent structures leading to compromised blood flow and various associated symptoms. They frequently affect young, otherwise healthy individuals and are often underdiagnosed due to their rarity and vague clinical manifestations. Achieving an accurate diagnosis depends on the integration of clinical presentation and imaging findings. Imaging modalities including color doppler ultrasound, computed tomography angiography, magnetic resonance angiography, and catheter-directed digital subtraction angiography are essential for diagnosis and management. Dynamic imaging is crucial in eliciting findings due to the positional nature of many of these syndromes. In this paper, we will present a "head-to-toe" overview of vascular compression syndromes including Vascular Eagle Syndrome, Vascular Thoracic Outlet Syndrome, Quadrilateral Space Syndrome, Hypothenar Hammer Syndrome, Median Arcuate Ligament Syndrome, Renal Artery Entrapment Syndrome, Left Renal Vein Compression/Nutcracker Syndrome, May-Thurner Syndrome, Adductor Canal Syndrome, and Popliteal Artery Entrapment Syndrome. Treatment is variable but typically involves a combination of conservative and surgical management. Surgical approaches focus on decompression of affected neurovascular structures. Endovascular treatment alone is rarely recommended. We aim to equip general radiologists with the knowledge needed to accurately diagnose patients with vascular compression syndromes, allowing for timely treatment.

Robotic median arcuate ligament release: a video vignette

Median arcuate ligament syndrome (MALS) poses a rare challenge in diagnosis and management. We present a case of MALS in a 50-year-old male with recurrent epigastric pain, vomiting, and diarrhea. Diagnostic imaging revealed celiac artery stenosis and gastroduodenal artery collateral dilatation. Robotic-assisted median arcuate ligament release successfully alleviated symptoms. Utilizing the da Vinci X system (Intuitive Surgical, Inc.), the procedure involved meticulous dissection of the celiac artery and surrounding tissue. Postoperative duplex ultrasound confirmed improved arterial flow. Literature underscores the diagnostic hurdles of MALS and the advantages of minimally invasive approaches over conventional open surgery. The robotic approach may help smoothen the learning curve associated with this procedure, by providing improved operative flexibility. Patient outcomes are excellent, with long-term symptom relief in most cases.

A radio-anatomical study of median arcuate ligament syndrome: unveiling the morphology and morphometry of median arcuate ligament, celiac trunk, and superior mesenteric artery

PURPOSE

In the context of medical literature, a significant lacuna exists in understanding median arcuate ligament syndrome (MALS). While clinical aspects are well documented, literature lacks a robust exploration of the anatomical relationship between the celiac trunk and the median arcuate ligament (MAL).

METHODS

Morphometric parameters, including the vertebral level of MAL origin, MAL thickness, celiac trunk (CeT) origin level, diameter, and distances between CeT/Superior Mesenteric Artery (SMA) and the MAL center were observed on 250 CT angiograms. Cadavers (n = 11) were dissected to examine the same parameters and histo-morphological examination of MAL tissue was done.

RESULTS

Radiological findings established average MAL thickness of 7.79 ± 2.58 mm. The celiac trunk typically originated at T12. The average distance between the celiac trunk and the MAL center was 1.32 ± 2.04 mm. The angle of the celiac trunk to the abdominal aorta was primarily obtuse. The average celiac trunk diameter was 5.53 ± 1.33 mm. Histological examinations revealed a diverse MAL composition, indicating variable mechanical properties.

CONCLUSION

This study provides comprehensive morphometric data on the anatomical relationship between the MAL and the celiac trunk. In contrast to available literature which says the average MAL thickness of > 4 mm is an indicator of increased thickness, we observed much higher average thickness in the studied population. The findings contribute to a better understanding of normal anatomical variations which can serve as reference values for accurate radiological diagnosis of MALS. The histological examination revealed the heterogeneous nature of the MAL tissue composition, suggesting variable mechanical properties and functions in different regions.

A Novel Minimally Invasive Robotic-Assisted Surgery Technique for Treatment of Median Arcuate Ligament Syndrome: A Case Report

Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome, is a rare but significant cause of chronic abdominal pain resulting from the extrinsic compression of the celiac trunk. This condition typically manifests with symptoms such as postprandial pain, nausea, vomiting, and weight loss, often leading to a diagnostic challenge due to its mimicry of other abdominal disorders. Diagnosis is based on exclusion and requires a high index of suspicion combined with precise imaging findings. This case report presents a 44-year-old female patient presenting with chronic abdominal pain, diaphoresis, and nausea, underscoring the complexity and diagnostic challenge of MALS, highlighting the significance of early intervention to mitigate morbidity and novelty treatment utilizing robotic-assisted surgical techniques. This report aims to contribute to the understanding of clinical presentations, diagnostic challenges, and treatment modalities of Dunbar syndrome, especially the option of minimally invasive robotic-assisted surgery for the treatment of this condition.

Median Arcuate Ligament Syndrome: A Case Report on a Rare Disease and Variant Hepatic Arterial Anatomy

Median arcuate ligament syndrome (MALS) is a rare gastroenterological illness that arises from the compression of the celiac trunk by the fibrous arch known as the median arcuate ligament, which connects the muscular tendon of the diaphragm to the vertebral column. It is hypothesized that this syndrome arises due to the inadequate caudal migration of the celiac trunk during embryogenesis, although the exact pathophysiology behind this disease process remains unclear. While MALS is classically associated with a triad of post-prandial pain, weight loss, and epigastric bruit, the triad is often incomplete due to variations in vascular structures with collateral circulation from adjacent vessels. When symptoms are present, they can be vague and often characterized as unexplained nausea, vomiting, diarrhea, or flatulence. Frequently, MALS is identified incidentally upon imaging of the abdomen in response to these nonspecific complaints. We present the case of a patient suffering from MALS in which a rare anatomic variant of the celiac trunk was identified.

Exploring celiac trunk parameters in median arcuate ligament syndrome: A CT study

PURPOSE

To assess anatomical variations in the celiac trunk (Ct) in patients with Median Arcuate Ligament Syndrome (MALS) using computed tomography (CT). The primary objectives were to investigate the celiac trunk angle (CtA), origin level, length (CtL), and their relationships with the superior mesenteric artery (SMA) in MALS patients. Additionally, the study intended to evaluate gender differences in these parameters and explore correlations between variables.

METHODS

Retrospectively, reports of abdominal CT scans taken between January 2018, and Sepmtember 2021, in the hospital image archive were screened vey two observers independently for MALS diagnosis. Parameters such as CtA, CtL, Ct-SMA distance, SMA angle (SMAA), and median arcuate ligament thickness (MALT) were measured. Statistical analyses were conducted using SPSS software.

RESULTS

Among the 81 patients (25 females, 56 males), significant differences were observed in MALT between genders (p = 0.001). CtA showed a negative correlation with CtL and Ct-SMA (p < 0.001), and a positive correlation was found between CtL and Ct-SMA (p = 0.002). CtL was measured as 25 mm for the all group. Origin levels of Ct and SMA were evaluated in comparison to vertebral levels. Ct-SMA distance was relatively shorter (9.19 mm) compared to the literature. SMAA findings were consistent with normal population values.

CONCLUSION

This study provided valuable insights into the anatomical parameters of the Ct ans SMA in MALS patients. Despite some differences compared to normal population parameters, no evidence supported the hypothesis of a superiorly placed Ct contributing to MALS.

Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review

Vascular compression syndromes are a diverse group of pathologies that can manifest asymptomatically and incidentally in otherwise healthy individuals or symptomatically with a spectrum of presentations. Due to their relative rarity, these syndromes are often poorly understood and overlooked. Early identification of these syndromes can have a significant impact on subsequent clinical management. This pictorial review provides a concise summary of seven vascular compression syndromes within the abdomen and pelvis including median arcuate ligament (MAL) syndrome, superior mesenteric artery (SMA) syndrome, nutcracker syndrome (NCS), May-Thurner syndrome (MTS), ureteropelvic junction obstruction (UPJO), vascular compression of the ureter, and portal biliopathy. The demographics, pathophysiology, predisposing factors, and expected treatment for each compression syndrome are reviewed. Salient imaging features of each entity are illustrated through imaging examples using multiple modalities including ultrasound, fluoroscopy, CT, and MRI.

Median arcuate ligament syndrome (Dunbar syndrome): A diagnosis not to be underestimated

Medial arcuate ligament syndrome (MALS) is an anatomoclinical entity underestimated in most situations due to the lack of specific signs. However, the consequences can be disastrous if the diagnosis is not seriously considered and investigations are not fully undertaken to confirm this hypothesis. We report a case of Median Arcuate Ligament Syndrome in a young woman who presented to the Emergency Department with moderate postprandial pain. All investigations were carried out promptly, with no abnormalities, and the diagnosis was retained on the evidence of a well-performed and appropriately interpreted abdominal CT. This case illustrates a rare cause of epigastralgia simulating a surgical emergency. This condition should be considered when biological and often radiological investigations are inconclusive. The relative youth of the patient is often suggestive, but confirmation is based on a CT scan with injection of a well-technical contrast product, or angiography. Treatment is debatable between a conservative approach and surgery. Surgical approach is discussed depending on the degree of vascular stenosis and the impact on the digestive tract. However, the recurrence of symptoms may be a contributory factor in the therapeutic decision. The impact could be lethal depending on the degree of stenosis and consequently on the repercussions on the digestive tract. A multidisciplinary approach is required for its management.

Overview of Median Arcuate Ligament Syndrome: A Narrative Review

Median arcuate ligament syndrome (MALS) is a rare disorder caused primarily by compression of the celiac trunk by the median arcuate ligament (MAL). This disorder typically results in patients presenting with bloating, weight loss, nausea, vomiting, and abdominal pain. The MALS diagnosis is one of exclusion, as the disorder has no specific diagnostic criteria. Imaging modalities are often utilized to assist in making the diagnosis, such as ultrasound, computed tomography angiography (CTA), and magnetic resonance angiography (MRA). These imaging modalities typically reveal a stenosed celiac artery with post-stenotic dilation in patients. This disorder is usually treated by dividing the MAL, thus relieving the compression of the celiac artery. The surgery may be done through either an open approach or a minimally invasive approach, which can be either laparoscopic or robot-assisted. Most patients respond well to this treatment, though certain factors that predict a poorer response to treatment include elderly age, a history of alcohol abuse, and psychiatric illness.

Median arcuate ligament syndrome often poses a diagnostic challenge: A literature review with a scope of our own experience

The median arcuate ligament syndrome (MALS) is recognized as a rare clinical entity, characterized by chronic post-prandial abdominal pain, nausea, vomiting, and unintentional weight loss. Due to its vague symptomatology, it is mainly regarded as a diagnosis of exclusion. Patients can often be misdiagnosed for several years before a correct diagnosis is established, also due to a medical team's clinical suspicion. We present a case series of two patients who suffered from MALS and were treated successfully. The first patient is a 32-year-old woman, presenting with post-prandial abdominal pain and weight loss that have lasted for the past ten years. The second patient, a 50-year-old woman, presented with similar symptomatology, with the symptoms lasting for the last five years. Both cases were treated by laparoscopic division of the median arcuate ligament fibers, which alleviated extrinsic pressure from the celiac artery. Previous cases of MALS were retrieved from PubMed, to assemble a better diagnostic algorithm and propose a treatment method of choice. The literature review suggests an angiography with a respiratory variation protocol as the diagnostic modality of choice, along with the laparoscopic division of the median arcuate ligament fibers as the proposed treatment of choice.