Epigastric Bruit Research Articles

Resolution of Celiac Artery Compression Syndrome Following Spinal Cord Stimulation: A Case Report

BACKGROUND: Celiac artery compression syndrome is characterized by postprandial epigastric pain, weight loss, and occasional epigastric bruit, and can be difficult to treat because there are no definitive guidelines. We present a case of a 47-year-old man who had postprandial pain, weight loss, and chronic diarrhea for 5 years, which was resolved with spinal cord stimulation (SCS). CASE REPORT: After extensive workup, a diagnosis of celiac artery compression syndrome was confirmed. Due to previous treatment failures, repeat celiac plexus blocks becoming less efficacious, and surgical unsuitability, the patient underwent an SCS trial. They continued having pain relief, so a permanent spinal cord stimulator lead was implanted. CONCLUSION: We highlight complete resolution of celiac artery compression syndrome using SCS. KEY WORDS: Case report, celiac artery compression syndrome, celiac plexus block, median arcuate ligament syndrome, spinal cord stimulation

Reversible 'Unstable' Abdominal Angina Caused by Ruptured Plaque of the Superior Mesenteric Artery: Clinical and Radiological Correlations.

Resembling unstable angina pectoris, ruptured atheromatous plaque in mesenteric vessels can develop, clinically manifested by new-onset abdominal angina.This condition may be reversible under treatment with antiplatelet medications and statins.Searching for abdominal bruit is invaluable in the assessment of unexplained abdominal pain.

Celiac Artery Aneurysm and Pseudoaneurysm Caused by Median Arcuate Ligament Syndrome (MALS) with Different Presentation: A Case Series

Introduction: The median arcuate ligament syndrome (MALS) is a rare vascular disorder caused by an extrinsic compression of the celiac artery from the median arcuate ligament.It is associated with aneurysmal dilatation due to compression. Although it usually comes with the classical triad of chronic abdominal pain, weight loss and epigastric bruit , it still manifests a wide variety of symptoms. Method: We observed 3 cases of celiac trunk aneurysm associated with this condition presented to us initially with different symptoms and MALS were detected by computed tomography scan. Results: Case 1: a 67 year old lady presented with epigastric pain underwent CT showed superior and inferior pancreaticoduodenal artery aneurysm. Successful angioembolisation of aneurysm done and proceeded with release of median arcuate ligament. Case 2: A 56 year old gentleman presented with symptoms of gastric outlet obstruction, CT scan showed duodenal mass with GDA pseudoaneuryms, Whipple procedure was performed. Case 3. A 51 year old gentleman presented with obstructive jaundice and was diagnosed with pancreatic head carcinoma, proceeded with Whipple procedure, only to discover common hepatic and superior anterior pancreaticoduodenal artery pseudoaneurysm post surgery via digital subtraction angiography. Conclusion: Aneurysms associated with MAL syndrome is quite rare and may present with different symptoms at time of diagnosis. Angioembolisation should be the treatment of choice and followup for recurrence is warranted.

Unexplained Chronic Abdominal Pain Manifesting as Celiac Artery Compression Syndrome

Celiac artery compression syndrome (CACS), also known as median arcuate ligament syndrome, is a rare condition which causes chronic recurrent abdominal pain related to compression of the celiac artery by the median arcuate ligament with resultant ischemia. Clinical presentation involves the triad of upper abdominal pain, weight loss and epigastric bruit in examination. The diagnosis is one of exclusion. The purpose of this case report is to describe a common presentation of an infrequently described rare disorder in literature. A 28-year-old healthy female presented to the emergency department (ED) with recurrent progressively worsening post-prandial sharp right upper quadrant abdominal pain for the past four months. Her pain has been associated with a 10-pound weight loss and intermittent episodes of nausea and vomiting without any fever, chills, diarrhea, or loss of appetite. She reported to no improvement with use of antacids, antiemetics and analgesics. She previously underwent outpatient ultrasonography revealing gallstones and esophagogastroduodenoscopy (EGD) revealing mild gastritis. Examination, laboratory studies, repeat ultrasound and computerized tomography (CT) scan revealed no acute abnormalities, including no gallstones. Due to nature of her chronic pain to be postprandial, a duplex ultrasound was ordered, which revealed elevated systolic velocities of the celiac artery, suggesting celiac artery stenosis and subsequently confirmed with angiography. Patient underwent a laparoscopic celiac artery decompression with a median arcuate ligament resection release. Patient was discharged following an uneventful postoperative period during her hospitalization. CACS is a rare syndrome. The pathophysiology, while not completely understood, is believed to be celiac arterial compression by variations in median arcuate ligament position. Patients are typically asymptomatic as the incidence of attributable clinical symptoms is much lower than the imaging finding. However, we present a case of a patient with chronic post-prandial pain and weight loss, in the absence of any obvious etiology, found to have a rare diagnosis of median arcuate ligament compressing on the celiac artery. We encourage clinicians to consider celiac artery compression syndrome in patients with chronic abdominal pain without a clearly established etiology.

GW27-e1251 Challenges in early diagnosis of celiac artery compression syndrome: a case report and review of the literatures

Celiac artery compression syndrome(CACS), also known as median arcuate ligament syndrome (MALS), is a rare cause of recurrent abdominal pain. CACS is seldom reported in oriental countries or regions. To report the early diagnosis of a CACS due to epigastric bruits and review the management

Laparoskopische Spaltung des Lig. arcuatum: die Behandlung des Truncus-coeliacus-Kompressionssyndroms

Objective: The coeliac artery compression syndrome, first described by Harjola und Dunbar, results from the coeliac artery and plexus being compressed by the arcuate ligament at their origin. The clinical symptoms are postprandial pain and weight loss and the syndrome significantly restricts patients' quality of life. In rare cases, an epigastric bruit is detected on clinical examination. Laparoscopic division of the arcuate ligament is a successful option for the treatment of the coeliac artery compression syndrome. Indications: Laparoscopic decompression is indicated for patients with a symptom triad of postprandial pain, weight loss and epigastric bruit and radiologic confirmation of coeliac artery compression by duplex sonography, computed tomography angiography or magnetic resonance angiography. Procedure: The operative strategy is based on the division of the arcuate ligament following its visualisation above the origin of the coeliac artery from the abdominal aorta. Conclusion: The laparoscopic division of the arcuate ligament and the resection of the coeliac plexus are a largely uneventful, minimally-invasive option to treat the coeliac artery compression syndrome and restore patients' quality of life.

Median Arcuate Ligament Syndrome Presenting as POTS

Introduction: Patients with POTS and persistent gastrointestinal symptoms warrant careful evaluation to identify vascular disorders such as Median Arcuate Ligament Syndrome (MALS) that occurs when the median arcuate ligament (MAL) impinges and compress the celiac artery (CA) & celiac plexus, resulting in varying degrees of CA stenosis and celiac plexus excitation. Methods: We searched our patient database from 02/2013- 03/2015 using the terms: POTS, Tilt, and MALS. MALS was diagnosed when Celiac artery Peak systolic velocity (PSV) was >2.5 m/s in expiration or ≥ 3 times the abdominal aorta PSV and 50-70%, CT-angio celiac artery stenosis. Results: 41 patients with MALS and POTS; (37 females and 4 males), median age 16.8 years, with abdominal pain (100%), fatigue (100%), nausea (100%), dizziness (100%), delayed gastric emptying (58%), weight loss(77%), vomiting (26%), epigastric bruit (38%), clammy extremities (72%), palpitations (94%), headaches (58%), syncope (12%). 27(65%) patients had hyperadrenergic POTS as within 10 minutes of Tilt HR increased (from 88 ± 4 to 136 ± 5 bpm), systolic BP (SBP) increased from 112 ± 4 to 132 ± 5 mm Hg, and SBP in late phase II of the Valsalva maneuver was 152 ± 5 versus 110 ± 7 in controls; P < 0.05, SBP overshoot in phase IV was 42 ± 4 versus 16 ± 3 mm Hg in controls; P < 0.05. CA PSV in expiration was 380 ± 45 m/s versus 142 ± 21 m/s in controls; P < 0.01. Median follow up-11.8 months- Post Laparoscopic division of MAL, resulted in resolution of orthostatic and gastrointestinal symptoms and Quality of life (QOL) score improvement from 43.2 preoperative to 84.6 postoperative; P < 0.01. Conclusions: MALS a potentially curable syndrome should be suspected in patients with POTS and gastrointestinal symptoms.

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The Median Arcuate Ligament Syndrome: A Mimicker of Mesenteric Vasculitis

The median arcuate ligament syndrome is an uncommon condition characterized by the triad of postprandial abdominal pain, unintentional weight loss, and an epigastric bruit. This condition is diagnostically challenging and patients often undergo extensive laboratory, radiographic, and invasive evaluations before it is identified. Physicians should consider this syndrome in the differential diagnoses of chronic abdominal pain and mesenteric vasculitis. Once diagnosed, treatment is generally surgical with known predictors of favorable and unfavorable outcomes. Surgical candidates should be selected carefully. We describe the cases of two young active duty patients diagnosed with median arcuate ligament syndrome after suffering from chronic abdominal pain. Both were referred to our rheumatology department to evaluate for mesenteric vasculitis. Each had a different therapeutic outcome.

Celiacomesenteric Trunk as a Cause of Median Arcuate Ligament Syndrome

A 28-year-old man presented with a constellation of symptoms with 6 months of duration, most prominent being unexplained weight loss of 35 pounds and postprandial abdominal discomfort. Multiple specialist consultations, laboratory and instrumental studies did not yield a unifying diagnosis. The patient had been treated with multiple medications without improvements. On examination, an epigastric bruit that increased with expiration and decreased with inspiration raised suspicion for median arcuate ligament syndrome (MALS). Ultrasonography of the mesenteric arteries revealed a rare anatomical variant of abdominal vessels known as celiacomesenteric trunk (the celiac artery and superior mesenteric artery sharing a common origin from the aorta). There was also a median arcuate ligament impression on the celiac artery and marked respiratory variations of Doppler velocities in support of the diagnosis of MALS. This is a case report of celiacomesenteric trunk clinically associated with MALS.

Index of Suspicion

Index of Suspicion

Circulation: Clinical Summaries

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PHYSICAL EXAMINATION FINDINGS IN FIBROMUSCULAR DYSPLASIA: A REPORT OF THE UNITED STATES REGISTRY FOR FIBROMUSCULAR DYSPLASIA

Results: Mean age at the time of enrollment was 55.7 +13.1 years (range 18-86 years) and 91% of pts were female. Mean BMI was 25.5 + 5.2 kg/ m2 and 48.8% of patients had a BMI > 25 kg/m2. Mean blood pressure on enrollment was 130/75 + 20/12.4 mmHg and 77.9% of pts were taking at least one blood pressure medication. 60% of pts reported significant headaches and 27.5% had pulsatile tinnitus. A cervical or epigastric bruit was a presenting sign that led to FMD diagnosis in 22.2% and 9.4% of pts, respectively. A neurological and vascular PE was recorded at the time of enrollment in 92.6% (414/447). Findings suggestive of Horner’s syndrome (pupil abnormality or ptosis) were reported in 12.4% of pts. Cranial nerve abnormalities were reported in 9.4% and other focal neurological deficits were reported in 13.6%. Bruits were reported over the carotid arteries (30.5%; 18.1% bilateral), epigastrium (17.5%), and flanks (6.1%; 3.2% bilateral). Among pts with reported imaging of the extracranial circulation (carotid and vertebral) and a documented PE, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of carotid bruit in predicting extracranial carotid FMD were 45.4%, 93.7%, 95.4%, and 37.4%, respectively. The sensitivity, specificity, PPV and NPV of epigastric and/or flank bruit in predicting renal and/or mesenteric FMD were 24.0%, 93.3%, 92.6%, and 26.0%, respectively.

The celiac axis compression syndrome (CACS): critical review in the laparoscopic era

The celiac axis compression syndrome (CACS) due to median arcuate ligament (MAL) was first described by Harjola in 1963; originating postpandrial abdominal pain, weight loss, epigastric bruit and celiac axis stenosis > 75% in angiographic studies. This clinical condition has been the origin of controversies about its pathogenesis, diagnosis and its long term clinical results. Advances in diagnostic imaging as 64 multidetector-row CT (MDCT), 3-D reconstruction, magnetic resonance (MR) and color duplex ultrasonography, provide better understanding of the syndrome and allow to identify the best candidates for surgical division of MAL fibers. Since the introduction of laparoscopic approach, and also endovascular procedures, in 2000, a new perspective has established in this challenging syndrome. With the occasion of our own experience, a critical review of the syndrome is presented.

A 41-year-old woman with paroxysmal abdominal pain, weight loss and an epigastric bruit

Case presentationDr. Picarelli: A 41-year-old woman, presenting with along history of severe recurrent abdominal pain, wasadmitted to our gastroenterology department.The pain was intermittent during the prior 4 yearsoccurring at no set time of day or night. The abdominalpain was related neither to food ingestion, bowel move-ment, nor to flatus or stool evacuation. Exercise andemotional stress frequently caused worsening of thesymptoms. In the previous year, she reported at least fourepisodes of admission to the emergency department (ED)because of severe abdominal pain partially resolving withantispastic therapy.The patient observed weight loss since the pain moti-vated a reduced intake of food. As the pain occurred afterstress, a psychotherapy was started, but provided no benefit.Anamnestic data did not show any family history ofinflammatory bowel disease, or cancer. The patient hadundergone a cesarean section, and as well had an appen-dectomy when she was age 12.Abdominal examination disclosed distension andbloating without peritoneal signs, and negative results ofinflammatory tests. Occult fecal blood test was negative aswell as small bowel X-ray examination.Differential diagnosisDr. Paris, Dr. Di Tola, Dr. Libanori, Dr. Donato: At thefirst clinical observation, the patient presented asymptom-atic with a soft and non-tender abdomen, without detect-able masses. The abdomen auscultation disclosed only aloud systolic bruit in the epigastrium with loss of intensityduring deep inspiration.The patient was tested for lactase deficit by a lactosebreath test. A patch test for nickel was negative. Celiacdisease was excluded by endomysial and transglutaminaseantibodies sera detection. The patient also had a gastros-copy and a colonoscopy that did not show any peptic,inflammatory lesions or tumor.Preliminary diagnosisDr. Picarelli: Recurrent chronic abdominal pain is fre-quently present in many gastrointestinal diseases. Never-theless the patient presented no observable structural orbiochemical alterations. The patient was therefore consid-ered to be affected by functional disorders. The diagnosisof irritable bowel syndrome (IBS) or functional dyspepsiawas considered, and dietary and pharmacological proce-dures were undertaken. Proton pump inhibitors, antispasticand antidepressive therapies were administered, but thesymptoms did not improve. The patient continued topresent abdominal pain with nocturnal weakness.

Takayasu Arteritis and Pregnancy from the Point of View of the Internist

To the Editor: Takayasu’s arteritis (TA) usually affects young women of childbearing age, sometimes coinciding with pregnancy. Both incidence and clinical expression are different depending on the geographic area, probably because of different HLA antigens associated1,2. Some observational studies attribute a better prognosis in Western patients3. Only a few Caucasian cases of TA and pregnancy have been published. We describe the clinical and epidemiological features of 4 successful deliveries in 3 patients with TA, underlining the most important data from the internist’s point of view. ### Case 1 A 22-year-old Caucasian woman was admitted because of malaise during the last 4 months and inflammatory back pain. At examination, blood pressure was 125/80 mm Hg, all pulses were symmetrically palpable, and an epigastric bruit was heard. Routine blood components showed hemoglobin 9’4 g/dl, mutated citrullinated vimentin antibodies (MCV) 76, and erythrocyte sedimentation rate (ESR) 150 mm/h. An arteriography demonstrated stenosis of abdominal aorta, including both renal arteries as well as mesenteric artery. Carotid artery was also affected (Figure 1A). She was diagnosed with TA, and prednisone (1 mg/kg) was started and then progressively tapered, with a progressive extinction of the symptoms and normalization of acute reactants. Figure 1. A. Case 1: arteriography showing affected carotid artery. B. Case 2: CT: aorta aneurysm. C: Case 3: DIVAS scan showing stenosis … Address reprint requests to Dr. Gasch. E-mail: urigasch{at}hotmail.com

Gastrointestinal: Celiac axis compression syndrome

A woman, aged 78 years, was investigated because of a 3-month history of nausea, anorexia and epigastric discomfort. She was known to have ischemic heart disease and had been previously treated by angioplasty and a coronary artery stent. On examination she had an epigastric bruit. Multi-slice computed tomography angiography (MSCT) of the coronary arteries did not reveal any significant stenoses. Because of the bruit, MSCT was extended to include the abdominal arteries. Images obtained with 40 × 0.625 mm slice collimation and a gantry rotation time of 50 milliseconds were reconstructed at 3 mm thickness with overlapping 1.4 mm slices. The lateral aortogram shows stenosis and poststenotic dilatation of the main celiac trunk apparently caused by the median arcuate ligament of the diaphragm (Fig. 1). There was also compensatory dilatation of the gastroduodenal artery, the superior pancreaticoduodenal artery and the inferior pancreaticoduodenal artery (Fig. 2). The latter arises from the superior mesenteric artery. As an initial attempt to dilate the stenosis with high-pressure balloon angioplasty was unsuccessful, she was subsequently treated with an Express Vascular stent using an Amplatz Super Stiff 0.035 guidewire (Boston Scientific, Natick, MA, USA). This appeared to result in a significant improvement in her symptoms. Stenosis of the celiac axis has been attributed to atheromatous plaques, fibrosis of the celiac ganglion and compression by the median arcuate ligament of the diaphragm. The latter is a fibrous arch that connects the right and left crura of the diaphragm and defines the anterior margin of the aortic hiatus. The ligament usually inserts superior and anterior to the celiac trunk. However, when it crosses the celiac trunk at a lower level, it may result in celiac axis compression and displacement of the celiac trunk towards the superior mesenteric artery. Compression can be accentuated during expiration. Whether celiac axis compression results in abdominal pain because of ischemia or other mechanisms is debated, particularly as many patients have enlarged collateral arteries. However, some patients appear to improve with a variety of operative procedures or with vascular stents. In the patient described above, images of the celiac trunk obtained by MSCT were of similar quality to those obtained by conventional angiography.

Celiac artery compression syndrome: unusual cause of chronic abdominal pain

Celiac artery compression syndrome is characterised by abdominal pain, usually related to the ingestion of food coexisting with arteriographic evidence of extrinsic compression of the celiac artery by the median arcuate ligament of the diaphragm. It is usually associated with weight loss and often with an epigastric bruit. Presentation of the case: a 58 year old woman was referred because of epigastric pain, starting four months before. The pain, characterised as often debilitating was not strictly related to meals. She lost 5kg of weight. Upper endoscope revealed an H.p. associated gastritis, but neither eradication of bacteria nor antispasmodic agents and PPI therapy offered significant relief. On physical examination an epigastric bruit was detected. Blood chemistry and thyroid function test were all normal. Colonoscopy, selective enterography and abdominal CT scan didn't reveal any pathology. Her pains persisted and she lost another 5kg. On duplex sonography velocity of the flow was markedly elevated at the level of origin of the celiac artery, corresponding to significant stenosis. Abdominal angiography revealed that the stenosis was caused by external compression, characteristic for median arcuate ligament syndrome. At laparatomy the median arcuate ligament was tensely tethered over the celiac artery, and a prominent thrill was palpable in the distal celiac artery. The arcuate ligament was completely divided without ganglionectomy. After the operation, her abdominal pain has completely resolved and 3 months later she regained 6kg. Celiac artery compression syndrome is a rare disorder. The diagnosis depends on the elimination of other possible causes for abdominal pain and the knowledge that this curious syndrome does indeed exist. In well selected patients the celiac artery compression can be corrected with a safe, relatively simple surgical procedure resulting complete relief of the long standing debilitating pain and a dramatic improvement in the quality of life of the patients.

Treatment of celiac and mesenteric arteries stenoses with interventional radiologic techniques

To evaluate the safety and efficacy of the interventional techniques for management of celiac and mesenteric arteries stenoses. Eight patients with celiac artery (CA) or superior mesenteric artery (SMA) focal stenotic lesions were treated with percutaneous transluminal balloon angioplasty (PTA) and stent placement. CA stenosis was present in 2 patients, SMA stenosis was present in 4, and both CA and SMA were involved in 2 patients. Postprandial pain was present in 4 patients, an epigastric bruit was present in 5. All patients presented with weight loss averaging 8 kg. The causes of the stenoses were atheroscleroses in 7 patients, median arcuate ligament syndrome (MALS) involvement of the CA in 1 patient. PTA and stent placement was technically successful in the 8 patients. Three patients underwent stent placement in CA, 5 patients in SMA. Seven patients were treated with 1 stent, one was treated with 2 stents. The post-procedural arteriograms showed good dilation of the stenotic lesions in all patients. The puncture site hematoma occurred in 2 patients without severe consequences. Complete alleviation of abdominal pain occurred in 5 patients, significant improvement in 2, and no improvement in 1 patient. At three months after the procedures, weights were regained in 6 patients. Clinical follow-up was available in all 8 patients, with a mean follow-up of 42 months (median 28 months, range 6 to 72 months). Follow-up Doppler ultrasound examinations showed normal flow patterns, without evidences of re-stenosis in the stenting arteries. Five patients remained asymptomatic, one patient had intermittent abdominal pain even the stenting SMA to be patent. Two patients respectively died of unrelated CA/SMA stenosis in 14 and 24 months after the treatment. PTA and stent placement are safe and effective methods for treatment of chronic CA and SMA focal stenoses, especially useful for these patients with a high surgical risk.