Median Arcuate Ligament Syndrome (MALS)

Posted by Kari Ulrich, Alumna Mentor @kariulrich, Dec 26, 2016

I am looking for other patients that have been diagnosed with Median Arcuate Ligament Syndrome. Although it is caused by compression of the celiac artery many people experience abdominal pain after eating, diarrhea, food avoidance. Usually the first doctors they see are GI doctors. It is a diagnosis that is made after everything else is ruled out. I am curious if anyone else has had surgery?

Interested in more discussions like this? Go to the Digestive Health Support Group.

@racheldmark

@ukmalsman @kariulrich @astaingegerdm

Thank you everyone for chiming in, with your support and suggestions.

You are all correct. It should NOT have come to this. When he was hospitalized for malnutrition and anxiety attack a few months ago, he was admitted to the ER, but not provided with food or drink, or IV fluids, or ANYTHING, and eventually he discharged himself. I WISH that I had been there, I want to scream at so many people that keep giving him this endless run around.

I appreciate the hope and advice that you are giving, but our outlook is so very grim right now, it's hard to hold out hope.

I want to impress upon you the severity of the situation we are in, and how heartbreakingly late in the game I have entered the picture. Lou is very weak and in a downward spiral. He is 6'2" and weighs 102 lbs, and continues to lose weight. We do believe there is another underlying condition that has gone untreated - as even drinking water causes him pain - but he is too weak to leave his bed, let alone his house to undergo examination or any follow up procedures.

I am trying to figure out if it's even possible to get him admitted to a hospital with IV fluids and feeding tube. BUT if we try to do this, they will immediately pull him of off of hospice care and I will be very blunt that hospice is the only thing keeping him alive right now. So I need to be absolutely SURE of our plan before taking any action.

Right now he is on a diet of:
+ 2 cups of Resource 2.0 over the course of the day (1/4 cup every hour)
+ Breakfast: 2/3 serving of oat meal with honey, butter, and 8 blueberries
+ Dinner: Chicken stock, butter, a tbsp of finely shredded chicken, and either egg drop or gluten free pasta

This only totals about 1,600 cal a day, and he really needs to be getting closer to 2000 to regain any weight. I am scrambling to read up on nutrition for him, just to get him stabilized, and I am afraid that there are things that are hurting him in the above plan, but I can't be sure.

Hospice care became a necessity because he couldn't get the pain and anxiety meds through his doctors. He has NOT had a PCP following him through this process, he has had to piece meal every appointment together by himself himself, and the Albuquerque medical facilities are absolutely horrendous.

I am home in LA for 24 hours, and return to Lou's tomorrow morning. I will review this meal plan with him and have ordered Fresubin, but it ships from the UK and will not get here until after Christmas.

Thank you again

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Your plan to keep him on hospice to try to get him stronger seems reasonable. People go on and off hospice often. It’s goal may be to help the dying but if you can get him the nutrition and support to get him stronger so you can get him treatment, then they will take him off once you seek treatment. Don’t feel bad about doing that. At this point it sounds like you don’t know exactly what is causing some of his symptoms. Yournot trying to deceive but your immediate goal is his care so hospice sounds reasonable until and if you know more and he can do more. Just saying use the resources you have available until you reach the next step.

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@racheldmark

@ukmalsman @kariulrich @astaingegerdm

Thank you everyone for chiming in, with your support and suggestions.

You are all correct. It should NOT have come to this. When he was hospitalized for malnutrition and anxiety attack a few months ago, he was admitted to the ER, but not provided with food or drink, or IV fluids, or ANYTHING, and eventually he discharged himself. I WISH that I had been there, I want to scream at so many people that keep giving him this endless run around.

I appreciate the hope and advice that you are giving, but our outlook is so very grim right now, it's hard to hold out hope.

I want to impress upon you the severity of the situation we are in, and how heartbreakingly late in the game I have entered the picture. Lou is very weak and in a downward spiral. He is 6'2" and weighs 102 lbs, and continues to lose weight. We do believe there is another underlying condition that has gone untreated - as even drinking water causes him pain - but he is too weak to leave his bed, let alone his house to undergo examination or any follow up procedures.

I am trying to figure out if it's even possible to get him admitted to a hospital with IV fluids and feeding tube. BUT if we try to do this, they will immediately pull him of off of hospice care and I will be very blunt that hospice is the only thing keeping him alive right now. So I need to be absolutely SURE of our plan before taking any action.

Right now he is on a diet of:
+ 2 cups of Resource 2.0 over the course of the day (1/4 cup every hour)
+ Breakfast: 2/3 serving of oat meal with honey, butter, and 8 blueberries
+ Dinner: Chicken stock, butter, a tbsp of finely shredded chicken, and either egg drop or gluten free pasta

This only totals about 1,600 cal a day, and he really needs to be getting closer to 2000 to regain any weight. I am scrambling to read up on nutrition for him, just to get him stabilized, and I am afraid that there are things that are hurting him in the above plan, but I can't be sure.

Hospice care became a necessity because he couldn't get the pain and anxiety meds through his doctors. He has NOT had a PCP following him through this process, he has had to piece meal every appointment together by himself himself, and the Albuquerque medical facilities are absolutely horrendous.

I am home in LA for 24 hours, and return to Lou's tomorrow morning. I will review this meal plan with him and have ordered Fresubin, but it ships from the UK and will not get here until after Christmas.

Thank you again

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Hi Rachel @racheldmark

Thanks for giving us clearer picture of his condition. Your uncle Lou is really in bad shape, I agree with @annief and yourself the hospice looks like it is keeping him alive, focusing on where he is is not important right now. The diet he is on maybe causing the pain, mainly the oatmeal and blueberries both are on the no list. Oats have soluble fiber in it that our small intestines find hard to digest we don't produce the enzyme to break it down. Oats are probably the worst thing on his menu, they made my life hell. It is because they stay in your system for a long time. People eat oats as they slowly release energy over the day and the fiber aids in digestion. You don't want to put anything in his digestive system that isn't easily digested.

For breakfast - white bread toasted with honey, pancakes or waffles made from refined white flour or yogurt without the fruit.
Dinner - pasta, noodles, mashed potato or soft white rice and I would mince the chicken, chicken stock.
dessert - custard, plain sponge pudding.

Right now you need to keep anything that is hard to digest out of his diet. I know the Resource 2.0 helps increase his calorie count but it contains fiber. Drastic steps need to be taken so I would change from Resource 2.0 to Resource Energy which contains no fiber but has less protein and calories.

Fresubin is great but make sure you order the fresubin Jucy, however if you change to Resource Energy which has no fiber you don't need the Fresubin.

When I did my research I came across this on the Mayo site

https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/low-fiber-diet/art-20048511

Although I can tolerate a little fiber in liquid form your uncle Lou needs to be on a zero fiber diet, anything hard to digest or non digestible needs to be off the menu. It is hard for us to get out of the habit of eating healthy, with MALs you really have to change your mindset, the primary goal is ease of digestion and not to aid digestion.

Remember anything white is alright.

If your uncle Lou is not on a high mineral and vitamin complex he will need to start taking them. They make a great deal of difference on how he will feel. I stopped taking mine for a week and I felt so lousy, brain fog increased and I was so lethargic I could barely move around.

Any questions feel free to ask.

Mark

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@racheldmark

@kariulrich Thank you for the warm welcome and quick response, I am very touched that you are reaching our personally, this must be a lot for you to manage.

Please be patient with me, I am very new to a lot of these terms, and am playing catch up to understand what stenosis is, or how invasive a TPN might be - I will respond to those points when I have a chance to talk to Lou (he is resting now).

Lou's story is very sad. Tracking back, we determined that his MALS may have started back in 1999, and went misdiagnosed and untreated for so long. The ABQ medical system has really failed him in this regard. Over the years he has seen many internal gastro specialists, but due to health care limitations he did NOT have a Primary Care Physician that was tracking his health deterioration over time.

In 2017, my parents (his older sister) flew him to MA to be seen at Mass General, and he was officially diagnosed with MALs. After that things swung into effect quickly, but keep in mind that he had been living with MALS for almost 20 years(!!!) at this point.

+ May 24, 2017 -- First diagnosed by Dr. Said at Mass. General
+ July 13, 2017 -- Surgery done at University of New Mexico Hospital. Cancer oncologist Dr. Nir and vascular surgeon Dr Rana. - Celiac artery release and cordiozation. Partial removal of celiac nerve ganglia.
+ Aug 4, 2017 -- Follow up complication 2 weeks later, Dr, Rana. Pseudoaneurysm of splenic artery. Surgery- Splenic embolization.
+ May 15 and June 20, 2018 Nerve blocks done at Albuquerque Pain Management Clinic. Anesthesiologist Dr. Whalen.

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Hi Rachel

I know this question has been asked already, but why was there a Cancer surgeon in the team when your uncle Lou had surgery July 13 2017 at New Mexico Hospital? Had they found cancer which was treated at the same time? I ask because I know some people will not talk about cancer if they have been diagnosed with it; they will hide it from friends and even family. You said you came in late to this so you may not have all the information. I suggest you have a one on one with your uncle and ask him to tell you everything or if he will allow you, go through his medical records.

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@ukmalsman

Hi Rachel

I know this question has been asked already, but why was there a Cancer surgeon in the team when your uncle Lou had surgery July 13 2017 at New Mexico Hospital? Had they found cancer which was treated at the same time? I ask because I know some people will not talk about cancer if they have been diagnosed with it; they will hide it from friends and even family. You said you came in late to this so you may not have all the information. I suggest you have a one on one with your uncle and ask him to tell you everything or if he will allow you, go through his medical records.

Jump to this post

@ukmalsman @kariulrich

Sorry, I meant to answer your questions about the Cancer surgeon and resent tests sooner! It is painful for Lou to talk about these thingsk about because looking back there are so many "what if's" and second guessing of everything that led him to this point. I don't want other's to suffer in the same way, so I will do my best to answer them. Please just understand that he is a bit sensitive to aggressive inquires, and I don't want him to feel that I am admonishing him for his choices or circumstances. I am putting together a write up of his medical history, and I will share it here when I have more complete information.

In answer to some of your questions, here is what I know:

> "why was there a Cancer surgeon in the team when your uncle Lou had surgery July 13 2017 at New Mexico Hospital?
Lou chose to be treated in NM by a Cancer surgeon because there are no vascular surgeons in NM, and if he went out of state he would have had to pay for the surgery out of pocket, due to his insurance. I do have access to his medical records and there was no signs of cancer. I also know that it was an open procedure and not laparoscopic.

> "What type of work up has he had since Aug 2017? Any ultrasounds, angiography such at CT or MRI??"
He had a CT scan a few months ago, and it showed that the arteries were not kinked, so there was no follow up for stents.

----------

Mark @ukmalsman

I will also stop oatmeal with berries tomorrow, thank you for that advice!

I can't seem to get Fresubin Jucy in the states, but my dad found that nestle makes a similar product called Boost breeze. Looking at Fresubin Jucy, the nutritional panel looks comparable. We are getting the Resource 2.0 that has no fiber, but I think we are open to trying something different since we can't really be sure if this has been working well or not.

I wish there was more time and room for experimentation, like you did on yourself.

We just ordered a case of Breeze and expedited it. My primary focus right now is to help reduce pain, and find foods that he can eat.

-----------

Thank you all, for your continued help and support. I return to NM tomorrow afternoon with more information in hand and that feels better.

--Rachel

REPLY
@racheldmark

@ukmalsman @kariulrich

Sorry, I meant to answer your questions about the Cancer surgeon and resent tests sooner! It is painful for Lou to talk about these thingsk about because looking back there are so many "what if's" and second guessing of everything that led him to this point. I don't want other's to suffer in the same way, so I will do my best to answer them. Please just understand that he is a bit sensitive to aggressive inquires, and I don't want him to feel that I am admonishing him for his choices or circumstances. I am putting together a write up of his medical history, and I will share it here when I have more complete information.

In answer to some of your questions, here is what I know:

> "why was there a Cancer surgeon in the team when your uncle Lou had surgery July 13 2017 at New Mexico Hospital?
Lou chose to be treated in NM by a Cancer surgeon because there are no vascular surgeons in NM, and if he went out of state he would have had to pay for the surgery out of pocket, due to his insurance. I do have access to his medical records and there was no signs of cancer. I also know that it was an open procedure and not laparoscopic.

> "What type of work up has he had since Aug 2017? Any ultrasounds, angiography such at CT or MRI??"
He had a CT scan a few months ago, and it showed that the arteries were not kinked, so there was no follow up for stents.

----------

Mark @ukmalsman

I will also stop oatmeal with berries tomorrow, thank you for that advice!

I can't seem to get Fresubin Jucy in the states, but my dad found that nestle makes a similar product called Boost breeze. Looking at Fresubin Jucy, the nutritional panel looks comparable. We are getting the Resource 2.0 that has no fiber, but I think we are open to trying something different since we can't really be sure if this has been working well or not.

I wish there was more time and room for experimentation, like you did on yourself.

We just ordered a case of Breeze and expedited it. My primary focus right now is to help reduce pain, and find foods that he can eat.

-----------

Thank you all, for your continued help and support. I return to NM tomorrow afternoon with more information in hand and that feels better.

--Rachel

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Rachel...please only share what you are comfortable with....please. We are here to support and privacy and confidentiality is first and foremost. It is absolutely fine to say you rather not share...I just want you to know that. No pressure. This is difficult for you too, caregiver wellness is so important. Please know we are here for both of you. Hugs

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@racheldmark

@ukmalsman @kariulrich

Sorry, I meant to answer your questions about the Cancer surgeon and resent tests sooner! It is painful for Lou to talk about these thingsk about because looking back there are so many "what if's" and second guessing of everything that led him to this point. I don't want other's to suffer in the same way, so I will do my best to answer them. Please just understand that he is a bit sensitive to aggressive inquires, and I don't want him to feel that I am admonishing him for his choices or circumstances. I am putting together a write up of his medical history, and I will share it here when I have more complete information.

In answer to some of your questions, here is what I know:

> "why was there a Cancer surgeon in the team when your uncle Lou had surgery July 13 2017 at New Mexico Hospital?
Lou chose to be treated in NM by a Cancer surgeon because there are no vascular surgeons in NM, and if he went out of state he would have had to pay for the surgery out of pocket, due to his insurance. I do have access to his medical records and there was no signs of cancer. I also know that it was an open procedure and not laparoscopic.

> "What type of work up has he had since Aug 2017? Any ultrasounds, angiography such at CT or MRI??"
He had a CT scan a few months ago, and it showed that the arteries were not kinked, so there was no follow up for stents.

----------

Mark @ukmalsman

I will also stop oatmeal with berries tomorrow, thank you for that advice!

I can't seem to get Fresubin Jucy in the states, but my dad found that nestle makes a similar product called Boost breeze. Looking at Fresubin Jucy, the nutritional panel looks comparable. We are getting the Resource 2.0 that has no fiber, but I think we are open to trying something different since we can't really be sure if this has been working well or not.

I wish there was more time and room for experimentation, like you did on yourself.

We just ordered a case of Breeze and expedited it. My primary focus right now is to help reduce pain, and find foods that he can eat.

-----------

Thank you all, for your continued help and support. I return to NM tomorrow afternoon with more information in hand and that feels better.

--Rachel

Jump to this post

Hi Rachel @racheldmark

As @kariulrich said share what you feels is comfortable both for you and your uncle. You wont need to talk to your uncle if you have access to his records. Something else I thought of, if your uncle has a blender at home you can increase his meal size by blending his food and turning it into soup. Blend cooked white rice, potato no skin and chicken add the chicken stock to thin down to a soup consistency. Hopefully he will be able to eat more and it will be more delicate on his digestive system.

For breakfast you could blend some boiled eggs add a little vegetable stock to thin down and spread on white bread, (most vegetable stock has zero dietary fiber.)

Mark

REPLY
@ukmalsman

Hi Rachel @racheldmark

As @kariulrich said share what you feels is comfortable both for you and your uncle. You wont need to talk to your uncle if you have access to his records. Something else I thought of, if your uncle has a blender at home you can increase his meal size by blending his food and turning it into soup. Blend cooked white rice, potato no skin and chicken add the chicken stock to thin down to a soup consistency. Hopefully he will be able to eat more and it will be more delicate on his digestive system.

For breakfast you could blend some boiled eggs add a little vegetable stock to thin down and spread on white bread, (most vegetable stock has zero dietary fiber.)

Mark

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@ukmalsman @kariulrich

I am back in NM! To help connect the dots, I asked Lou for his Mayo Clinic user name, @ruudolpho

He is reading your emails and responses along with me, and we are both very touched with all of the information you have given us! I went grocery shopping and picked up more goodies to try. I just served Lou his first bowl of instant mashed potatoes - with butter, coconut/almond milk, and chicken stock - he liked it and he said his pain is very low! This is encouraging.

Is all fiber a big NO-NO? I just bought some baby food of pureed apples and chicken and will hold off on trying it out if it may be an issue.

--Rachel

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@racheldmark

@ukmalsman @kariulrich

I am back in NM! To help connect the dots, I asked Lou for his Mayo Clinic user name, @ruudolpho

He is reading your emails and responses along with me, and we are both very touched with all of the information you have given us! I went grocery shopping and picked up more goodies to try. I just served Lou his first bowl of instant mashed potatoes - with butter, coconut/almond milk, and chicken stock - he liked it and he said his pain is very low! This is encouraging.

Is all fiber a big NO-NO? I just bought some baby food of pureed apples and chicken and will hold off on trying it out if it may be an issue.

--Rachel

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Awesome I was on pure and soft foods for about 6 months and graduated. To the next step. I now can tolerate everything as long it is very small portions 4-6 times a day as tolerated. There is hope keep it up.

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Hey everyone,

This is a new topic of conversation for me, has anyone tried Ketamine infusion treatment for chronic nerve pain reduction?

A friend of mine had amazing results with depression treatment so I thought I would look into it. I just contacted this local clinic and will let you know what I find out. Reading through the Infusion Clinic of Albuquerque's website has extensive documentation on recent research that looks very promising: infusionclinicabq.com/providers

Thanks,
--Rachel

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@racheldmark

@ukmalsman @kariulrich

I am back in NM! To help connect the dots, I asked Lou for his Mayo Clinic user name, @ruudolpho

He is reading your emails and responses along with me, and we are both very touched with all of the information you have given us! I went grocery shopping and picked up more goodies to try. I just served Lou his first bowl of instant mashed potatoes - with butter, coconut/almond milk, and chicken stock - he liked it and he said his pain is very low! This is encouraging.

Is all fiber a big NO-NO? I just bought some baby food of pureed apples and chicken and will hold off on trying it out if it may be an issue.

--Rachel

Jump to this post

Hi @racheldmark

Fiber is a definite NO at the moment. Fruit in any form is a no at the moment too. No fruit or no veg, fiber, pulses, beans, nuts, seeds.
Veg and fruit that are green have chlorophyll in which we can't digest, even pureed apples may increase his pain. If you can keep his fiber down to a minimal value it should be good for him. I would check the baby food chicken, usually they are whole meals which include veg. Stick to pasta, potato and rice, a little minced chicken for protein. I suggested kids breaded chicken sticks because they are basically made from mashed up chicken reformed into chicken sticks. Stick with the potato for a while to see if the pain gets any better and to allow the fibrous food to get out of his system. Remember take it slowly.

Hi @ruudolpho
Welcome to the website and the MALS family. When you eat do you get pain straight away or after an hour or so. With me the pain would get worse after a couple of hours, some people get pain straight away. When I was doing my research I realized that I was eating the wrong foods twice a day causing a never ending cycle of pain. Drinking water made it worse, from what I researched your bowel pulls in water to aid in digestion. The best way to put it is imagine your gut as a furnace and the flames are the pain you feel, white foods are paper, fast burning little flames, hard to digest foods like fiber and fatty fast foods are like wood and coal burning hotter for longer with bigger flames. Water acts like the accelerant gasoline, on paper it makes little difference, however gasoline on coal/wood your furnace is burning at its peak with huge flames. Great for a healthy person, that's what they need day to day but not so great for MALs sufferers. For MALs sufferers the furnace needs to burn low and steady.

Your first meal is encouraging lets hope it continues.

Mark

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