2762 Median Arcuate Ligament Syndrome: A Rare but Overlooked Cause of Post-Prandial Abdominal Pain

Abstract

INTRODUCTION: Median arcuate ligament syndrome (MALS), also known as celiac artery compression syndrome or Dunbar syndrome, is defined as chronic recurrent abdominal pain related to compression of the celiac artery by the median arcuate ligament. The median arcuate ligament is a fibrous arch that crosses the aorta and links the crura of the diaphragm. This ligament typically passes superior to the origin of the celiac artery, however about 10% of the population (with strong female predominance) has a low-lying ligament that causes compression of the celiac trunk that is usually asymptomatic. We report a case of median arcuate ligament syndrome presenting similar to chronic mesenteric ischemia but without the typically associated cardiovascular risk factors. CASE DESCRIPTION/METHODS: A 54-year-old woman with no significant past medical history presented to the emergency department with a 6-month history of post-prandial abdominal pain associated with nausea, nonbilious emesis, sitophobia and a 60lb weight loss in the past 6 months. Vital signs were unremarkable. Her physical exam was entirely benign aside from mild epigastric tenderness to deep palpation. Labs were significant for a WBC 11.4, Hb 19.0 (baseline 13-15), K + 2.9. Gastroenterology was consulted and the patient underwent EGD which showed normal appearance of the esophagus, stomach, and duodenum with negative biopsies. Due to concern for mesenteric ischemia, the patient underwent CT Angiography of the abdomen which demonstrated 70% stenosis of the proximal celiac artery highly suggestive of median arcuate ligament syndrome. All other vessels were patent. DISCUSSION: Median arcuate ligament syndrome is a rare cause of post-prandial abdominal pain and weight loss that can often be challenging to diagnosis unless suspected by the clinician. Many patients undergo extensive workups for abdominal pain before being diagnosed. This syndrome presents similar to chronic mesenteric ischemia however many of these patients lack the typical cardiovascular risks factors associated with mesenteric ischemia as the demographic for MALS is typically middle-aged females ranging from age 40-60 years old. Patients are also often misdiagnosed with functional dyspepsia. Patients diagnosed with this disease should undergo laparoscopic celiac artery decompression which cures the majority of the patients with symptom recurrence occurring in approximately 6% of patients.