Arcuate Ligament Syndrome
Also known as celiac artery compression syndrome, median arcuate ligament syndrome (MALS) involves an arch-shaped ligament that goes around the aorta and connects the diaphragm and spine. It occurs when this ligament presses too much on the celiac artery (a major aorta branch that delivers blood to the liver, stomach, and other organs) along with the surrounding nerves. The ligament behaves like a hammer and the celiac axis like an anvil, causing the nerves between them to become compressed. The result is abdominal pain which worsens upon eating.
Upper abdominal pain after eating is the main symptom of MALS. This often leads to the avoidance of eating (anorexia), which in turn leads to weight loss, sometimes in excess of 20 pounds. Crouching or lying facedown can ease the pain.
Although symptoms are similar to those of mesenteric ischemia, MALS is differentiated by the fact it occurs at a young age, and most commonly in women.
The median arcuate ligament usually makes contact with the aorta above the celiac artery. However, in up to 25% of normal individuals, the ligament passes in front of the celiac artery which compresses the celiac artery and surrounding structures. For some, the compression causes median arcuate ligament syndrome.
There are several theories as to why this compression causes pain. One is thought to be a decrease in blood flow to abdominal organs. Another is that not only is the celiac artery compressed, but also the celiac ganglia, which may be the actual source of the pain.
A suspicion of MALS calls for a complete exam, review of medical history, and various ttests. These may include blood work as well as imaging tests to rule out other, more common causes of your symptoms. Once these conditions are ruled out, a special ultrasound will be used to check blood flow through the celiac artery and compression of the celiac plexus.
In some cases, typical symptoms of MALS are not present. Patients may not lose weight or have the same type of pain. In these instances, if MALS is still suspected, a nerve block on the celiac nerves will help to diagnose the problem.
Traditionally, patients with MALS undergo a surgical procedure to release the ligament and put an end to the compression of the celiac artery. A technique called neurolysis breaks up the celiac nerves.
There is, however, a minimally invasive option. Laparoscopic surgery is a technique involving 5 small incisions rather than the traditional one large. Your surgeon will use instruments inserted into these incisions to divide the nerves (neurolysis), separate the median arcuate ligament, and stop the pressure placed on the celiac artery.
Relieving pressure is a key part of treatment, but neurolysis is needed in addition to fully relieve symptoms and end pain after eating. A normal diet can resume the following day after surgery.