Case Presentation: 75 yo female with a 20 year history of chronic dyspepsia, H. pylori, and C. difficile presented to the Emergency Department complaining of worsening nausea and two days of hematochezia. The patient stated new onset dysphagia to both solids and liquids. In the 2 months prior to presentation, patient recalls frequent episodes of abdominal pain requiring multiple ED visits and a weight loss of 15lbs. On initial examination, the patient was found to be afebrile and normotensive with laboratory results showing a WBC count of 19.3×103 cells/µL, hemoglobin of 16.0 g/dL, and platelet count of 307 x 103 cells/ µL. Physical exam was normal except for the abdomen which was mildly tender to palpation in the LUQ and LLQ without rebound or guarding. Patient was admitted and placed empirically on piperacillin / tazobactam (3.375g IV, every 8 hours). Abdominal CT demonstrated wall thickening, trace fluid, and adjacent fat stranding involving the distal transverse, descending, and proximal sigmoid colon likely representing an infectious or inflammatory colitis with a patent inferior mesenteric artery. EGD was only positive for mild antral erythema and few duodenal erosions with no ulcers and samples were obtained to test for H. pylori. Under direct visualization with colonoscopy, biopsies were obtained in areas showing erythema and congestion consistent with ischemic colitis. A duplex ultrasound was performed, revealing a peak systolic velocity (PSV) within the celiac artery of 285 cm/s, correlating to >70% occlusion. The previous CT results were examined retrospectively and mild compression of the celiac trunk by the median arcuate ligament was noted. A diagnosis of median arcuate ligament syndrome (MALS) was made.
Discussion: MALS, or celiac artery compression, is an anatomic abnormality causing vascular compression. Variation in the location of either the fibrous band of the median arcuate ligament or the origin of the celiac trunk results in stenosis. This causes ischemia and delayed gastric emptying. Our case demonstrates the extensive workup patients endure prior to being accurately diagnosed with MALS. Given the patient’s long history with chronic nausea, H. pylori, and other vague gastrointestinal complaints, MALS was low on the differential diagnosis. This is a typical occurrence due to non-specific symptomology of MALS and the need to rule out more common etiologies.
Conclusions: We present a case of MALS which depicts a rare diagnosis, initially presenting with vague symptoms such as postprandial epigastric pain and weight loss. These non-specific complaints mimic more common conditions, delaying proper diagnosis and treatment. It is prudent to consider MALS as a cause of chronic mesenteric ischemia when evaluating patients with unresolved abdominal pain and weight loss to prevent delay in curative surgical treatment.
To cite this abstract:Villania, CA; Melendez, FP; Shillingford, KS; Casadesus, D. AN ANATOMICAL EXPLANATION FOR A CHRONIC GASTROINTESTINAL COMPLAINT. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 906. https://www.shmabstracts.com/abstract/an-anatomical-explanation-for-a-chronic-gastrointestinal-complaint/. Accessed April 10, 2020.