An Anatomical Explanation for a Chronic Gastrointestinal Complaint

Abstract

Introduction: Median Arcuate Ligament Syndrome (MALS) is an anatomic abnormality causing vascular compression. Variation in the location of either the fibrous band of the median arcuate ligament or the origin of the celiac trunk results in stenosis. This causes ischemia and delayed gastric emptying. Our case demonstrates the extensive workup patients endure prior to being accurately diagnosed with MALS. Case: 75 yo female with a 20 year history of chronic dyspepsia, H. pylori, and C. difficile presented to the ED complaining of worsening nausea and two days of hematochezia. The patient stated new onset dysphagia to both solids and liquids. 2 months prior to presentation, she recalls frequent episodes of abdominal pain requiring multiple ED visits and weight loss of 15lbs. On initial examination, the patient was found afebrile, normotensive, with laboratory results showing a WBC count of 19.3x103 cells/μL, hemoglobin of 16.0 g/dL, and platelet count of 307 x 103 cells/ μL. Physical exam showed an abdomen mildly tender to palpation in the LUQ and LLQ without rebound or guarding. Patient was admitted and placed empirically on piperacillin / tazobactam. Abdominal CT demonstrated wall thickening, trace fluid, and adjacent fat stranding involving the distal transverse, descending, and proximal sigmoid colon likely representing an infectious or inflammatory colitis with a patent inferior mesenteric artery. EGD was only positive for mild antral erythema and few duodenal erosions with no ulcers and samples were obtained to test for H. pylori. During colonoscopy, biopsies obtained showed erythema and congestion consistent with ischemic colitis. A duplex ultrasound was performed, revealing a peak systolic velocity (PSV) within the celiac artery of 285 cm/s, correlating to >70% occlusion. The previous CT results were examined retrospectively and mild compression of the celiac trunk by the median arcuate ligament was noted. A diagnosis of median arcuate ligament syndrome (MALS) was made. Conclusions: We present a case of MALS which depicts a rare diagnosis, initially presenting with vague symptoms such as postprandial epigastric pain and weight loss. These non-specific complaints mimic more common conditions, delaying proper diagnosis and treatment.It is prudent to consider MALS as a cause of chronic mesenteric ischemia when evaluating patients with unresolved abdominal pain and weight loss to prevent delay in curative surgical treatment.