Median Arcuate Ligament Syndrome (MALS)

Hi @evrose23! After discussion with my vascular surgeon, open procedure was the only option for me. I have an underlying vascular disease and laporoscopic would have put me at a greater risk. I believe that there is better visualization in the open procedure vs laparoscopic, and it really depends on the patient's age and how long they have been diagnosed. Children are a whole different story, and laparoscopic seems to have a great success rate. For me, my artery did not open up after the ligament release so I had to have a bypass done. Let me know how your CTA goes!

http://www.thij.org/doi/full/10.14503/THIJ-12-2495?code=txhi-site
Article Citation:
Fernando Vazquez de Lara, Christopher Higgins, and Eduardo A. Hernandez-Vila (2014) Median Arcuate Ligament Syndrome Confirmed with the Use of Intravascular Ultrasound. Texas Heart Institute Journal: February 2014, Vol. 41, No. 1, pp. 57-60.
doi: http://dx.doi.org/10.14503/THIJ-12-2495
Case Reports
Median Arcuate Ligament Syndrome Confirmed with the Use of Intravascular Ultrasound

Fernando Vazquez de Lara, MD, Christopher Higgins, MD, and Eduardo A. Hernandez-Vila, MD, FACC
Address for reprints: Eduardo A. Hernandez-Vila, MD, FACC, 6624 Fannin St., Suite 2870, Houston, TX 77030
E-mail: eduardohernandezmd@gmail.com

Median arcuate ligament syndrome, a rarely reported condition, is characterized by postprandial abdominal pain, nausea, vomiting, and weight loss. Its cause is unclear. We present the case of a 45-year-old woman who had intermittent chronic positional abdominal pain without weight loss. Magnetic resonance angiograms and computed tomograms revealed stenosis of the celiac artery. Ostial compression was confirmed on catheter angiographic and intravascular ultrasonographic images. Intravascular ultrasound revealed far greater stenosis than did the initial imaging methods and confirmed a diagnosis of median arcuate ligament syndrome. In lieu of surgery, the patient underwent a celiac ganglion block procedure that substantially relieved her symptoms.

To our knowledge, this is the first report of the use of intravascular ultrasound in the diagnosis of median arcuate ligament syndrome. We recommend using this imaging method preoperatively in other suspected cases of the syndrome, to better identify patients who might benefit from corrective surgery.

Keywords: Abdominal pain/etiology, arterial occlusive diseases/diagnosis/pathology/physiopathology, celiac artery/pathology/physiopathology/ultrasonography, constriction, pathologic, diagnostic imaging, ligaments/pathology, mesenteric vascular occlusion/complications/etiology, ultrasonography, intravascular

© 2014 by the Texas Heart® Institute, Houston

http://www.practicalgastro.com/pdf/February15/Median-Arcuate-Ligament-Syndrome.pdf
Richard W. McCallum, MD, FACP, FRACP (Aust), FACG
Median Arcuate Ligament Syndrome

Median arcuate ligament syndrome is an uncommon disorder rst described in the 1960s. It is characterized by epigastric abdominal pain accentuated by meals and weight loss associated with nausea, vomiting and gastroparesis. Abnormal gastric electrical rhythm has also been reported. Abdominal bruit is a striking feature that is present in some cases. It is a diagnosis of exclusion that should be considered when there is a subjective presentation of severe epigastric and right upper quadrant abdominal pain which is out of proportion to objective ndings. Whether using Doppler study, CT angiography, MRA or angiography, the main and most important goal is assessing both inspiratory and expiratory phases of the celiac artery to demonstrate reduction in the compression during inspiration. The treatment is surgical release of the median arcuate ligament to achieve decompression of the celiac artery and the celiac plexus. An evolving role for endoscopic ultrasound both in diagnosis and management is also discussed.

I am looking for support from those who have had this surgery. I had mine on March 30 and am struggling with the continued nausea. I had open surgery....not fun!

@artistgma nausea can be a problem if you are advancing your diet too fast. Also the pain medication can contribute to nausea. I would use Reeds Ginger Ail in between meals, or following a meal. You need to eat 8-10 very small meals a day starting out, and advance very slowly. It was at least a year before I could tolerate eating 3 meals a day, even then sometimes I apt for more frequent smaller meals. Eating things that easy to digest, I would have white toast and malt a meal. What types of food are you eating? Are you eating and drinking fluids at the same time?

I have not been diagnosed with MALS as of yet though my CT scan shows narrowing of the celiac trunk.
In late October I was diagnosed with a DVT in my lower calf, a week later I was diagnosed with a PE. The following week I went in with signs of a stroke, the doctor sent me home with no testing after I told him I did not want morphine. Shortly after this I developed severe abdominal pain. The pain is chronic, though it goes from dull moderate to severe, worsened by eating, even the smallest amount. Since mid November I have lost just over 23 pounds. My questions are, has anyone else had the same kind of issues? Can a blood clot or stroke cause MALS?

Hi Kari. I am 59 years old and was just diagnosed with MALS on Monday (two days ago) after having many tests run over the past year by my PCP and my GI doctor. After a year and no diagnosis, I went to Ohio to get second opinion at the Cleveland Clinic where it was confirmed with a Doppler Ultrasound and a CT Angiography after the doctor heard a bruit in my abdomen. I have severe stenosis of the celiac artery (368). However, the surprising thing is, I do not have the type of pain the vascular surgeon typically sees with MALS patients. I have had some pain, on and off, for the past four years under my right rib, but it is mild. For me, the symptoms that make me miserable are: gas pain, bloating and slight nausea. I also have malabsorption and have lost about 10 pounds due to getting full so quickly. I was wondering if you or anyone else on this board have gas or indigestion as a symptom of MALS? I am so scared to do the surgery, it is all very overwhelming right now. Thanks

@coffeelatte very nice to meet you! I think every MALS patient is a bit unique in their pain and the exact location. I was just speaking with another MALS/FMD patient tonight and we discussed how there is the pain and then there is also GI problems that go along with the MALS that seem to linger on for many MALS patients after the surgery. Many of us report malabsorption issues to our physicians both before and sometimes after the surgery. For me the surgery stopped the severe pain that I experienced after eating and during exercise. I still deal with GI motility issues, however they have been under control with the use of fiber and probiotics. Gas and bloating before surgery was severe and after surgery are manageable. Surgery is a big commitment and the recovery time is long, depending on the type of surgery. There is not a "text book" case for MALS... so it does not surprise me your symptoms maybe different. Here are some questions to think about: Are your symptoms affecting your quality of life? Have you avoided situations because of your symptoms? Have you and your physician tried every possible treatment? It is very overwhelming, but you are not alone in this! Learn everything you can and make an educated decision either way. How is your family taking this? Do you have support?

@bree11 I do not believe a blood clot can cause MALS, but they could cause identical symptoms, if it happened in an artery involving your abdomen. Does that make sense? If you have a clot in the brain, you will have symptoms depending on where the clot is. If you have ischemia (decreased oxygen flow) in your tummy you can have severe abdominal pain. I believe your symptoms warrant further work up. I have had severe abdominal pain from my Mals, due to ischemia. ( I hope this is making sense to you) Have you had any GI work up? What other testing have you had done? Please remember you are your best advocate.

Hi Kari,
I have had endoscopy and colonoscopy, CT's, ultrasounds, x-rays and lots of blood work, with no results aside from the narrowing seen on the celiac trunk. I will be going in to see a GI in the next couple of weeks and she wants to do another endoscopy and colonoscopy. I do understand what you are saying about the ischemia and am on blood thinners and will remain on them indefinitely as clotting runs in my family and this was my second diagnosed unprovoked DVT, first PE. I am working at being my own advocate and just recently found a new doctor, though he was unaware of MALS and is looking into it further for me.