Median arcuate ligament syndrome (MALS), also known as celiac artery compression syndrome or Dunbar syndrome, is a rare condition involving the compression of the celiac artery by the median arcuate ligament. This article explores MALS, its symptoms, causes, diagnosis, treatment options, and the potential role of dietary modifications in managing the condition.
Understanding Median Arcuate Ligament Syndrome (MALS)
MALS occurs when the median arcuate ligament, a band of tissue that connects the diaphragm to the aorta, presses on the celiac artery and nearby nerves (celiac plexus). The celiac artery is a major branch of the aorta that supplies blood to the stomach, liver, spleen, and pancreas. Normally, the median arcuate ligament sits above the celiac artery. In MALS, the ligament is lower than usual, causing compression of the celiac artery. This compression can reduce blood flow to the abdominal organs and put pressure on the surrounding nerves, leading to pain and other symptoms.
Symptoms of MALS
The primary symptom of MALS is upper abdominal pain that typically occurs after eating. The pain can be intense, leading to a fear of eating and potential weight loss. Other symptoms associated with MALS include:
- Bloated stomach
- Diarrhea
- Nausea and vomiting
- Unexplained weight loss (20 pounds or more)
It's important to note that pressure on the celiac artery doesn't always cause symptoms. MALS symptoms can be vague and mimic other conditions, making diagnosis challenging.
Causes and Risk Factors
The exact cause of MALS remains poorly understood. Some experts believe that individuals may be born with a misplaced median arcuate ligament. Another theory suggests that MALS can develop as a complication of abdominal or spinal surgery or abdominal trauma.
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Since the cause of MALS is not well-defined, the risk factors are also unclear. However, MALS appears to be more common in adults than in children. Some studies indicate it usually occurs in young, thin females.
Potential Complications
If left untreated, MALS can lead to chronic pain, which can significantly impact a person's quality of life. The persistent pain may result in:
- Mental health issues like depression and anxiety
- Fear of eating
- Significant weight loss
Diagnosis and Treatment of MALS
Diagnosing MALS can be challenging due to its rarity and the similarity of its symptoms to other conditions. If your stomach pain continues despite home care, call your healthcare professional. If your stomach pain is bad and activity or movement makes it worse, call your healthcare professional immediately. Sometimes upper stomach pain can be confused with chest pain. Sometimes chest pain can be due to a heart attack.
Diagnostic Tests
Healthcare providers may use various tests to diagnose MALS, including:
- CT angiography: This imaging technique uses X-rays and a contrast dye to visualize the celiac artery and surrounding structures, helping to identify any compression.
- Angiography: This invasive procedure involves inserting a catheter into an artery to inject contrast dye and take X-ray images of the blood vessels. Angiography can provide detailed information about the celiac artery and the extent of compression.
- Duplex ultrasound: This non-invasive imaging technique uses sound waves to assess blood flow in the celiac artery.
Treatment Options
The primary treatment for MALS is aimed at relieving the compression of the celiac artery and alleviating symptoms. Treatment options may include:
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- Celiac plexus block: This procedure involves injecting a local anesthetic into the celiac plexus, a network of nerves near the celiac artery, to block pain signals.
- Median arcuate ligament release surgery: This surgical procedure involves cutting or releasing the median arcuate ligament to relieve pressure on the celiac artery. The procedure can be performed through open surgery or laparoscopically (using small incisions and a camera). This procedure restores blood flow through your celiac artery and removes pressure on nearby nerves.
Surgery often eases symptoms. But research shows median arcuate ligament syndrome can come back after surgery. You can’t keep that from happening. But knowing what changes in your body may mean MALS is back may help. Ask your healthcare provider about early changes. They’ll be glad to explain what may be signs of trouble.
The Role of Diet in Managing MALS
While surgery is often the recommended treatment for MALS, dietary modifications can play a significant role in managing symptoms, particularly in individuals who are not candidates for surgery or who prefer a conservative approach.
Dietary Strategies for MALS
There is no specific diet that is universally recommended for MALS. However, some dietary strategies may help reduce symptoms and improve overall well-being:
- Small, frequent meals: Eating smaller meals more frequently throughout the day can help reduce the burden on the digestive system and minimize postprandial pain.
- Avoid trigger foods: Keeping a food diary to track symptoms can help identify specific foods that trigger pain or other symptoms. Common trigger foods may include fatty foods, spicy foods, caffeine, and alcohol.
- Focus on easily digestible foods: Choosing foods that are easy to digest can help reduce the workload on the digestive system. Examples of easily digestible foods include cooked vegetables, lean proteins, and refined grains.
- Stay hydrated: Drinking plenty of fluids, especially water, can help prevent constipation and promote healthy digestion.
- Consider a low-FODMAP diet: FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) are a group of carbohydrates that can be poorly absorbed in the small intestine, leading to gas, bloating, and abdominal pain. A low-FODMAP diet may help reduce these symptoms in some individuals with MALS.
- Weight management: Maintaining a healthy weight may help reduce pressure on the celiac artery. In some cases, weight gain has been associated with symptom relief.
A Case Study: Dietary Changes and Weight Gain
A 56-year-old female patient was evaluated for a 3-week history of postprandial epigastric pain. The pain radiated to her back, sometimes with a cold sweat. Those symptoms started 2 hours after taking food, mostly after dinner, and continued for 2-3 hours. She had no appreciable past medical history and took no medicine. She was a nonsmoker and drank a can of beer most days of the week. On examination, her height was 146.4 cm, body weight 42.9 kg, BMI 20.02 kg/m2, blood pressure 150/90 mmHg, heart rate 64 beats per minute and regular, body temperature 36.1°C and respiratory rate 18 breaths per minute. There was no sign of anemia or jaundice in her conjunctiva. Her abdomen was soft with slight tenderness around her subumbilical area. A subtle epigastric bruit was detected on careful auscultation. Her routine laboratory studies were all normal. A plain CT of her abdomen showed no particular findings except for a left ovarian cyst. We advised her to keep a daily food diary after meals and record her symptoms to examine potential relationships between them. As a result, we discovered she experienced the same type of postprandial epigastric pain four times over the next fortnight. Each symptom started 2-4 hours after dinner or lunch and continued for 2-4 hours. She ate various types of foods, and there were no specific foods or beverages (including alcoholic) that related to those symptoms. We performed contrast‐enhanced CT and suspected stenosis on her origin of the celiac artery (Figure 1). Therefore, we consulted a radiologist who performed an angiography to investigate the condition of her celiac artery in detail. The result of her angiography revealed a stenosis of the origin of the celiac artery due to the median arcuate ligament indenting upon the celiac trunk and causing downward angulation. Additional findings included retrograde filling of the celiac axis from the superior mesenteric artery through a well‐developed pancreaticoduodenal arcade (Figure 2). Stasis of the hepatic artery was seen on the angiography due to this retrograde filling. The range of retrograde filling of the celiac artery became wider during the expiratory phase than during the inspiratory phase, suggesting the stenosis became more severe during expiration. Retrograde filling of the celiac artery (CA) from the superior mesenteric artery (SMA) through a well‐developed pancreaticoduodenal arcade (PDA) (arrows)
We explained the mechanism of this syndrome and presented the option of surgical treatment to her, but she refused. Therefore, we started conservative management to monitor progression of the symptoms. Through her diary she found that taking less food at dinner and increasing the number of meals lessened the severity of the postprandial symptoms. Two months later, she gained back her former weight, to around 45 kg, and no symptoms have occurred since.
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This case highlights the potential benefits of dietary modifications and weight gain in managing MALS symptoms.
Consulting a Dietitian
It is essential to consult with a registered dietitian or healthcare professional to develop an individualized dietary plan that meets your specific needs and addresses any underlying nutritional deficiencies.
Living with MALS
Living with MALS can be challenging, but with proper diagnosis, treatment, and management strategies, individuals can improve their quality of life. In addition to medical and dietary interventions, consider the following:
- Seek support: Join a support group or connect with other individuals with MALS to share experiences and learn coping strategies.
- Manage stress: Stress can exacerbate MALS symptoms. Practice stress-reducing techniques such as yoga, meditation, or deep breathing exercises.
- Maintain a healthy lifestyle: Engage in regular physical activity and get enough sleep to promote overall well-being.
- Communicate with your healthcare team: Keep your healthcare team informed about your symptoms and any changes in your condition.
tags: #celiac #artery #compression #syndrome #diet