Median arcuate ligament syndrome (MALS)
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Median arcuate ligament syndrome (MALS) develops when the artery that supplies blood to the upper abdomen is compressed by the arc-shaped band of tissue in the chest region. The celiac artery is the name of the vessel. Some persons who have MALS have stomach ache.
Each person has a somewhat different position for the celiac artery and median arcuate ligament. Typically, the ligament crosses the body’s largest blood vessel (aorta) over the celiac artery, where it is located. But occasionally, the ligament or artery may be misaligned, leading to MALS. Moreover, the ligament may exert pressure on the celiac artery’s surrounding nerve system (celiac plexus).
MALS can strike anyone, including children. The MALS is also known as celiac axis syndrome, Dunbar syndrome, or celiac artery compression.
Surgery is used as a form of treatment to relax (decompress) the ligament and reopen the artery.
Symptoms
Compression of the celiac artery frequently goes unnoticed.
But, stomach pain that lasts for a long time (chronic) is a potential symptom of median arcuate ligament syndrome (MALS). The celiac artery may be blocked or nearby nerves may be compressed, which would cause the symptoms.
MALS may manifest the following symptoms:
- Upper middle stomach pain that may subside as you lean forward
- Abdominal discomfort with eating, exercising, or shifting body positions
- Bloating
- Diarrhea
- Nausea and vomiting
- Significant weight loss, typically more than 20 pounds, as a result of fear of eating because of pain
Stomach pain can have many distinct reasons. Call your healthcare professional if your stomach pain does not go away after receiving home care. A thorough physical examination and testing are required to identify the root reason.
Call your provider right away if your stomach discomfort is severe and getting up or moving makes it worse. If your stomach ache is accompanied by any of the following:
- Yellowish discoloration of the eyes and skin (jaundice)
- Extreme sensitivity to touch in the area around your belly
- Chronic nausea and vomiting episodes
- Abdominal swelling
- Bloody stool
- Fever
Upper stomach pain can occasionally be mistaken for chest pain. Heart attacks can sometimes be the cause. If you have chest or upper stomach discomfort with or without any of the following symptoms, get emergency assistance.
- Chest pressure, fullness, or tightness
- A piercing or crushing pain that radiates to your jaw, neck, shoulders, and one or both of your arms
- Aches and pains that persist longer than a few minutes or get worse as you move about
- Difficulty of breathing
- Vomiting
- Nausea
- Cold sweats
- Weakness
- Dizziness
Causes
The actual cause of median arcuate ligament syndrome is unknown to medical professionals. There is debate concerning the origins and diagnosis of MALS.
Risk factors
The risk factors for MALS are uncertain because it is unclear what causes the illness. MALS has been observed in children, including twins, suggesting that genetics may be involved.
After pancreatic surgery and a traumatic blunt abdominal injury, some patients experienced MALS.
Diagnosis
A particular test is not available to identify MALS. Your doctor will thoroughly examine you and inquire about your symptoms and medical background.
When using a stethoscope to listen to your upper stomach region, your doctor might hear a bruit. When a blood vessel is blocked or constricted, the sound is heard.
To help rule out more widespread causes of your symptoms, your doctor may also request specific testing, such as imaging and blood tests. They consist of gastritis, gastroparesis, Gastroesophageal Reflux Disease (GERD) or condition related to liver, pancreas, liver, spleen or intestine problems.
Your doctor can eliminate other causes of stomach discomfort with the aid of blood test and imaging studies.
The following tests may be performed to rule out other conditions and identify MALS:
- Blood exam. These examinations are performed to look for issues with the liver, pancreas, kidneys, and other organs. The quantity of white blood cells and red blood cells can be determined by a complete blood count. White blood cell counts over normal may indicate an infection.
- Abdominal ultrasound. High-frequency sound waves are used in this noninvasive procedure to examine blood flow through blood arteries. In particular, when breathing deeply in and out, it can indicate whether the celiac artery is constricted.
- Upper endoscopy. Also known as esophagogastroduodenoscopy (EGD), this technique. It is carried out to observe the stomach, esophagus, and upper small intestine (duodenum). After administering numbing medicine, the doctor performs an EGD by carefully guiding an extended, flexible tube with a camera on the end (endoscope) down the throat. During this operation, the clinician has the option to obtain tissue samples (biopsy).
- Gastric emptying studies. The rate at which the stomach empties can be slowed by celiac artery compression. To ascertain how quickly the stomach discharges its contents, gastric emptying tests are conducted. Several medical disorders may contribute to slow or delayed stomach emptying.
- Magnetic Resonance Imaging (MRI). An MRI creates finely detailed images of the body region being studied using strong magnets and radio waves. A blood artery may occasionally be injected with dye to help visualize how blood flows through arteries and veins (magnetic resonance angiogram).
- Computerized Tomography (CT) of the abdomen. In a CT scan, particular body components are imaged in cross-section using X-rays. If the celiac artery is obstructed or constricted, an abdominal CT scan might reveal this. To see blood flow in the arteries and veins more clearly, a healthcare professional will occasionally inject dye into a blood vessel (CT angiogram).
Treatment
The only available treatment for MALS is surgery. Medial arcuate ligament release, also known as median arcuate ligament decompression, is the most popular surgery. Often, it is performed as an open procedure. It can occasionally be performed using a minimally invasive technique (laparoscopic or robotic).
A surgeon divides the median arcuate ligament and the network of stomach-regional nerves (celiac plexus) while you are sedated. The artery has extra space as a result. It relieves pressure on the nerves and improves blood flow.
Some MALS patients may need open surgery to adequately repair or replace a blocked celiac artery and restore blood flow (revascularization).
Following the MALS release surgery, you will normally stay in the hospital for 2 to 3 days. You’ll need an ultrasound one month after surgery to confirm that blood flow through the celiac artery has been fully restored. Research have shown that surgery to release the median arcuate ligament is safe even in children with MALS. It frequently results in immediate pain alleviation and improves the quality of life for the person.
