From the Guidelines
Median arcuate ligament syndrome (MALS) typically presents with chronic abdominal pain, particularly after eating, as its primary symptom, along with other symptoms such as nausea, vomiting, bloating, and diarrhea, as noted in the most recent guidelines 1. The pain associated with MALS is usually located in the upper middle abdomen (epigastrium) and may radiate to the back. Weight loss is common due to food aversion, as patients learn that eating triggers pain. Some patients experience a bruit (abnormal sound) in the upper abdomen that can be heard with a stethoscope.
Key Symptoms
- Chronic abdominal pain, especially after eating
- Nausea
- Vomiting
- Bloating
- Diarrhea
- Weight loss due to food aversion
- Abdominal bruit in some cases These symptoms occur because the median arcuate ligament, a fibrous arch connecting the diaphragm crura, compresses the celiac artery and celiac ganglion, particularly during expiration, reducing blood flow to abdominal organs and irritating nearby nerves, as discussed in 1 and 1.
Diagnosis and Considerations
Diagnosis is typically made with a combination of clinical findings and imaging findings, including a proximal narrowing of the celiac artery in a “J-shaped” configuration, as mentioned in 1. The condition is often diagnosed after excluding other causes of abdominal pain, using imaging techniques like Doppler ultrasound, CT angiography, or MR angiography that can show the arterial compression. Given the potential for significant morbidity and impact on quality of life, it's crucial to consider MALS in the differential diagnosis of chronic abdominal pain, especially when other causes have been ruled out, as suggested by the guidelines in 1 and the radiologic management criteria in 1.
From the Research
Symptoms of Median Arcuate Syndrome
The symptoms of median arcuate syndrome (MALS) include:
- Postprandial epigastric abdominal pain 2, 3, 4, 5, 6
- Weight loss 2, 3, 4, 5, 6
- Nausea and vomiting 2, 3, 4, 5, 6
- Food fear 3
- Exercise-induced epigastric pain 3
- Abdominal bruit 4
- Periumbilical pain 5
Demographics
MALS is most often identified in:
- Young women 2, 3, 6
- However, it can also occur in young males 5
- Typically affects women between the ages of 20 and 40 years 6
Diagnosis and Management
Diagnosis of MALS can be challenging, and it is often a diagnosis of exclusion 3, 5, 6
- Diagnostic tools include:
- Mesenteric arterial duplex ultrasonography 6
- Computed tomography (CT) 5, 6
- Magnetic resonance (MR) 6
- Conventional contrast angiography 6
- Fractional flow reserve and intravascular ultrasound 6
- Management options include: