From the Research
Introduction to Minimal Narrowing of the Coeliac Axis
The diagnosis for minimal narrowing of the coeliac (celiac) axis with no diagnostic evidence of median arcuate ligament syndrome (MALS) can be challenging due to the lack of specific symptoms and diagnostic criteria.
Definition and Causes
MALS is a rare vascular disorder caused by an extrinsic compression of the celiac artery from the median arcuate ligament, prominent fibrous bands, and ganglionic periaortic tissue 1. However, in cases where the narrowing of the coeliac axis is minimal and does not meet the diagnostic criteria for MALS, other causes should be considered.
Diagnostic Considerations
The diagnosis of MALS is traditionally made with conventional angiography; however, three-dimensional computed tomographic (CT) angiography can also be used to demonstrate the characteristic focal narrowing in the proximal celiac axis 2.
Key Diagnostic Features
In patients with MALS, CT angiograms demonstrate a characteristic focal narrowing in the proximal celiac axis with a hooked appearance, which can help distinguish this condition from other causes of celiac artery narrowing, such as atherosclerotic disease 2.
- The presence of postprandial and exercise-induced epigastric pain, nausea, vomiting, food fear, and weight loss can be indicative of MALS 3.
- The duration between the onset of symptoms and diagnosis of MALS can extend up to years, making it essential to consider MALS in the diagnostic work-up for patients with symptoms of abdominal pain not attributable to more common conditions 3.
Differential Diagnosis
In cases where the narrowing of the coeliac axis is minimal and does not meet the diagnostic criteria for MALS, other causes of abdominal pain and weight loss should be considered, such as:
- Atherosclerotic disease
- Viscoal ischemia
- Inflammatory bowel disease
- Irritable bowel syndrome
Treatment Options
The treatment of MALS typically involves surgical division of the ligament and reconstruction of the celiac artery 1, 4.
Surgical Intervention
Open surgical therapy is a safe and reliable procedure with no mortality and low morbidity 1.
- Decompression of the celiac artery can be performed alone or in combination with vascular reconstructive techniques, such as aorto-celiac vein interposition or patchplasty of the celiac artery with vein 1.
- Endovascular treatment with percutaneous transluminal angioplasty and insertion of a stent is not recommended as a primary treatment for MALS, as it does not address the underlying cause of extrinsic compression and may require open procedures during the long-term course 1, 4.
Conclusion
In conclusion, the diagnosis for minimal narrowing of the coeliac axis with no diagnostic evidence of MALS requires a thorough evaluation of the patient's symptoms, medical history, and diagnostic imaging results.
Key Takeaways
- A comprehensive diagnostic work-up, including CT angiography and clinical evaluation, is essential to rule out MALS and other causes of abdominal pain and weight loss.
- Surgical intervention, including decompression and vascular reconstruction, may be necessary to relieve symptoms and improve quality of life in patients with MALS.
- A multidisciplinary approach, involving primary care physicians, vascular surgeons, and other specialists, is crucial for the diagnosis and management of MALS and other complex vascular disorders 3.