A 52 year‐old man presented with six months of abdominal pain and fifty‐pounds of weight loss. He had coronary artery disease, atrial fibrillation, diabetes mellitus, hyperlipidemia, and remote tobacco use. His pain only occurred post‐prandially and was associated with nausea and vomiting. He had no symptoms of reflux or dysphagia and had no history of cancer. Over a six‐month course, he had presented to multiple providers and undergone repetitive diagnostic tests to no avail.
He had mild tachycardia and hypertension, an irregular heart rhythm and normal breath sounds. His abdomen was obese and distended, with normoactive bowel sounds and tenderness in the right upper quadrant and epigastric regions. There was neither guarding nor rebound.
He had a normal complete blood count and the following lab Results:
total protein of 7.5 gm/dL, albumin of 3.4 gm/dL, aspartate aminotransferase of 50 u/L, alanine aminotransferase of 71 u/L, alkaline phosphatase of 433 u/L, amylase of 17 u/L, and lipase of 120 u/L. His hemoglobin‐A1c was 11%.
Esophagogastroduodenoscopy (EGD) revealed hypertrophic gastritis and further studies showed normal gastric emptying. Angiography revealed a 60‐65% ostial stenosis of the celiac trunk with an 8 mmHg pullback gradient and 40% ostial stenosis of the inferior mesenteric artery with zero pullback gradient. Computed tomography (CT) with angiogram revealed diaphragmatic crural thickening with celiac trunk compression consistent with MALS.
Abdominal pain is a common compliant amongst hospitalized medicine patients and the differential diagnosis is vast. It is best to sort the differential diagnosis based upon the location and characterization of the pain. Biliary disease, pancreatitis, gastroesophogeal reflux, and dyspepsia are frequent causes of post‐prandial epigastric pain. In the presence of poorly controlled diabetes or coronary disease, diabetic gastroparesis and mesenteric ischemia should be added to the list of possible causes.
Median arcuate ligament syndrome, also known as celiac artery compression syndrome, is a rare condition caused by compression of the celiac trunk by the median arcuate ligament of the diaphragm. This leads to reduced forward flow through the celiac artery causing abdominal pain, nausea, vomiting, and weight loss. The workup for MALS involves endoscopy and gastric emptying studies to rule out more common etiologies of abdominal pain including reflux, dyspepsia, malignancy, and gastroparesis. Imaging must be obtained to confirm a stenotic lesion and decreased flow at the celiac artery. Duplex ultrasound can be used as a screening tool, though angiography or CT angiography has more diagnostic utility. The diagnosis of MALS is difficult since it is largely one of exclusion and, due to its rarity, may not be considered in the initial differential. Physicians must be disciplined to reassess and broaden their differential to include more rare causes when common etiologies are excluded. This is particularly true for patients with a higher pre‐test probability of more common etiologies based on their risk factors. MALS is a treatable condition—minimally invasive laparoscopic artery decompression can successfully provide symptom relief.
MALS is one of the rarer diagnoses that occur with post‐prandial abominal pain; however, recognition of this disease can lead to minimally invasive symptomatic treatment.
To cite this abstract:Avalos J, Harlan P. My Intestinal Dismals. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 326. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/my-intestinal-dismals/. Accessed March 31, 2020.