Median Arcuate Ligament Syndrome (MALS)

Dear jmmb, I suffer from median arcuate ligament compression with high grade stenosis of the celiac and sma arteries. I found this out after a year of treating my symptoms through a GI doctor. In the course of a year (2016) I had most of the tests everyone else has had, in addition, my GI did a hydrogen breath test for SIBO and one for fructose intolerance. I came back with a very high score for both. I have taken a total of five rounds of Xifaxin, two rounds of Flagyl (metronidazole) and one 14-day course of Diflucan (100 mg) to address the SIBO. My weight had dropped 20 pounds in a four month period with no end in sight so I stayed the course for months taking the antibiotics and anti-fungal. And I did get a bit better. For me, the SIBO treatment seemed to reduce the nausea and stopped the weight loss. I was not able to gain weight, but it helped me to feel a bit better. I have malabsorption issues, which my GI doctor could not figure out. I had a repeat breath test last December (2016) after a full year of treatment and it showed my SIBO numbers for both methane and hydrogen had gone way down. So the GI doctor was able to address the SIBO but I did not feel much better and was not able to absorb food very well. He felt I needed to see a psychologist. I am 60 years old and I know my own body pretty well. I knew this was a physical issue and not a mental one. However, I did go see the psychologist he referred me to and she said during our visit that I needed a second opinion immediately and she got me an appointment to see a GI doctor at the Cleveland Clinic. One month later, the GI doctor at Cleveland looked over all my tests and said, "have and of your doctors ever considered this may be a blood flow issue?" Within a day, I had the Doppler ultrasound and CTA which confirmed 99% stenosis of the celiac artery and over 70% stenosis of the SMA. I was in shock and scared to death. I was referred to a vascular surgeon and a general surgeon at Cleveland who both felt I should not have the surgery (yet) because I do not have the intense pain that goes with MALS. Instead I have a constant, colicky pain, lots of gas, bloating and indigestion, but not the nerve pain most patients report. They said my blood flow seems to be adequate, but not optimal, so that is most likely the cause of the SIBO and malabsorption. I then saw a vascular surgeon back in my city and he felt the same. He said there is enough blood flow to be adequate right now. He said that malabsorption is highly associated with MALS but is not correlated. I share my story in the hopes it may help you. In my situation, it seems to be a condition that I will have to manage daily, and may or may not need to have surgery. I follow a low residue diet and avoid all fruit and many vegetables. I don't like it, but managing the SIBO has enabled me to put back on the 20 pounds I lost. I watch my symptoms very carefully and if I start to drop weight again, I will try a round of the antibiotic and if that does not work, I will know it is time to consider more aggressive treatment. I feel like the other shoe could fall at any time but I try to stay hopeful. Some days it is not possible because I feel so lousy. Other days can be pretty good. I wish you well.

@coffeelatte thank you so much for your sharing. We are very similar. I have to be honest 2 arteries blocked at that high a stenosis is concerning. I can understand they may be concerned about an open surgery, but what about stent placement to open them? Have you seen a surgeon who has dealt with many MALS patients to get their opinion? As far as the sibo, if you go to Dr. Allison Siebecker's web site it is loaded with great information, diets, recipes links, etc. I have learned so much about the sibo from her. I am glad it seems your sibo is under control, but the bloating after eating is a key symptom for me. Many naturopathic drs seem to know more about sibo and treatment. I definitely believe the stomach issues all come from the blood flow. It is a vicious cycle, and I don't know how we get out of it. The malabsorption is also from sibo. It makes it so your body can't absorb the nutrients. I take folic acid, B1, iron, vit d, daily. Are you tired all the time? I have chronic fatigue, but I am wondering how much of my fatigue is also from the sibo, and or MALS. Well thank you for you reply and good luck to you. Keep me posted as to how you are doing.. Oh and as to the drs thinking it is all in our heads, they should take a look at this site, we cant all be crazy!!!!!HaHa

Hi Kari, I am in need of a good gastroenterologist, and a general doctor in the Scottsdale area. I am new to Scottsdale, and do not know anyone to get these names, and referrals. Please let me know a.s.a.p. with some names, and hopefully phone #'s.

Thanks so much!

J.P.

Jmmb, I totally agree with you. Knowing I have two arteries that are as compressed as mine is very nerve wracking to me. However, in meeting with both vascular surgeons and the general surgeon, all three said I have developed collateral blood flow. It is their opinion this is what is giving me enough blood flow, but not optimal. I understand this collateral blood flow to be alternate circulation around the blocked arteries by nearby small blood vessels. I can feel the tightness and pull of the median arcuate ligament if I take in a really deep breath and try to expand my ribcage as far as possible. I also can feel it when I do the back stroke in the pool. It feels so tight and hurts when I have stretched it. When I first went to Cleveland Clinic, I had an appointment with a well known GI doctor. He first sent me to an interventional cardiologist. When I went to see him, he did not feel I should have a stent placed because he said the ligament could crush it, move it, or tear the artery. He called in a second interventional cardiologist who said the very same thing. They referred me to the vascular surgeon, Dr. Parks. He is (was) the only vascular surgeon at CC doing the MALS surgery. I just received a letter informing me he has taken a position in another country so I will have to wait and see who will replace him.

As for the SIBO, I researched it until I was blue in the face. I am very familiar with Allison Siebecker's work and her website. I listened to many of her youtube videos when I was desperate for help and to keep my hopes up. For me, the antibiotics were critical. I was so low in B12 that I was put on a prescription for them along with vitamin D. I will have my levels checked again next week when I see my PCP. My B12 was so low (under 200) that my doctor wanted to do shots, but I wanted to see if the tablets would work. I don't think they have because I am so exhausted there are no words to describe it. I have felt this way for over a year now. It has to be the MALS and SIBO. I dread SIBO being a chronic problem for me but I suspect it already is. My GI doctor where I live wants me to do one week of antibiotics every month. I may give it a try. The GI doctor in Cleveland totally disagrees. He wants me to have the surgery right away. I asked him what my percentage was that it would help the GI symptoms that I deal with and he said 10%. I said would you do that huge surgery for a 10% chance of it helping and he said yes. I am not so brave.

Wow coffeelattee, we are so similar....I have heard of the regiments for sibo and one week a month is one of them. That was one of my biggest problems, getting someone to follow up and see what else after a round of them. I finally got a prescription company to get me the xifaxim for $35 a month and a $90 annual fee. These are for meds that are continuous. My insurance wouldn't cover it and then when I got on Medicare, which is horrible in Arizona. If you are on social security disability you can't get supplemental insurance. Stupidest thing I ever heard of. Obviously I'm sick if on disability and not working, how am I suppose to afford medical care.....anyway I wont get going on that....I had to pick a prescription plan separate from medicare and most didn't cover it. A few that did the copay was $600 for one round of antibiotics. No way I could do that especially when who knows for how long. So now I have a bunch in my medicine cabinet waiting to use. My last gi doc said to take a round again, but why waste it if there was no one to test me right after and follow up. She was moving and I was moving and going to Mayo. I was hoping they would, but doesn't look that way. I don't know how they don't see how it is all connected, the GI and arteries especially when they are the arteries to the stomach!!! It is so frustrating. Aren't you tired of being your own dr.
As far as surgery, I would go by what the vascular surgeon says, not the GI. Plus if GI knows you have sibo, that should be treated regardless of surgery or not. It is interesting about the collateral blood flow by alternate circulation. I spent so much time on sibo research I disregarded anything else with my arteries. Plus who wants to think anything else with them. I could never do another open surgery, at least not yet, but my surgeon said it is inevitable. Just a question of how long the stents last..
I'm sorry but you may have already told me, but did you have any surgery on your arteries at all yet? I developed sibo, well at least serious symptoms I didn't have before, after my surgery.

I forgot one question. About the tightness and pull on artery. Sometimes , more often than not, I feel like it is hard to take a deep breath, like I can't get enough air in. It's hard to explain. when they asked me if I have shortness of breath, I tried to describe this, and they (Mayo GI) just said no that's nothing. I wonder is it anything like that type of feeling? I do have a lot of scar tissue. I can't bend to my left side to well. It feels like there is a big brick or something blocking me.

I wish I was familiar with the Scottsdale physicians, unfortunately I am not. I hope someone on here knows of someone. Have you looked on the MALS Pals Facebook page, they have a list of peer recommended physicians, but I believe the list is vascular surgeons.

Jmmb, you will have to remind me what surgery you have had. I have not had surgery for MALS release but 13 years ago I had a hysterectomy and my gall bladder removed at the same time and I have had GI problems ever since. I feel the SIBO may partly be a result of scar tissue from those surgeries. For me, the compressed arteries were an incidental finding after many of the tests I had came out normal (gastric emptying, abdominal CT, liver MRI, endoscopy, colonoscopy, blood tests) except for the fat malabsorption test, breath tests for SIBO and fructose intolerance, B12 and D. The compressions are significant so when I went to Cleveland the GI doctor could hear the bruit through his stethoscope. I struggle most with the GI symptoms. I do feel a tightness and pressure in my sternum but I can live with it if it does not get worse. It does not make it hard to take a deep breath. If it does, at least I don't have to go through all the testing and various doctors again. I know what the problem is now. I agree with you about the GI's advice to go ahead with the surgery. I won't do it unless a vascular surgeon says it is time.

coffeelatte, I had an open surgery for what they found when they went in was that my diaphragm was compressing my celiac and superior mesenteric arteries. Tests showed they were severely compressed and needed surgery right away, but they didn't know it was due to diaphragm till they went in. I guess it is very unusual I am told. Then a year later I had stents put in each artery since they were narrowed again significantly. I was to weak to go through another open surgery. Sibo usually does develop from some sort of abdominal surgery....I've done all the testing too, and like I said, like you the malabsorption issues. I did show some weird things on my gastric emptying; small intestine empties faster than average, then the other numbers were right at the low mark, but they didn't say anything. I will ask about that when I go back to see gi doc. I really don't need another issue, but I feel like they just look inside the box, if something isn't flag they don't look at the numbers, but some of my numbers are up and down and 1 point from the low , things like that. My naturopathic dr. I went to who first diagnosed the sibo said that to me. She said they need to look at the whole picture and person. Not everyone fits into a perfect box. Anyway I just wonder if I'll ever feel 'normal' whatever that is again. There are good days, my "good" days which a "normal" person would feel crappy, you know what I am saying and then those you don't want to get out of bed. It is nice to talk to someone who gets it. Sorry you have to deal with it too, but it is comforting to know we are not alone, if that makes sense.....

worriedmom and atjmoney I feel for your family and your daughters. They are to young to be dealing with this, they should be enjoying life. Hopefully since they are so young they will fight this early in life and not have to deal with it later in life when it can be more challenging. I thought about them as I was replying to coffeelatte saying it is comforting to know we aren't alone, but not fair for such young girls to have to deal with this....Just my thoughts are with you all