Median Arcuate Ligament Syndrome: A Rare Cause to be Considered in Cases of Non-Specific Upper Abdominal Pain

Introduction: The Median arcuate ligament syndrome (MALS) is a cause of chronic abdominal pain affecting both children and adults. MALS also known as celiac artery compression syndrome (CACS) can be symptomatic, presenting as chronic abdominal pain, nausea, vomiting, weight loss and diarrhoea.

Case Report: 49 years old male presented with complaints of recurrent abdominal pain aggravated after meals. CT angiography of abdomen revealed focal narrowing of the celiac artery at its origin with a thin filling defect, characteristics hooked appearance and linear hypodense band suggestive of MALS. Laparotomy was done and division of median arcuate ligament (MAL) and celiac plexus destruction was done.

Discussion: MAL is a fibrous arch that unites the diaphragmatic crura on either side of aortic hiatus, with the normal anatomic location of the ligament being superior to the origin of the celiac axis. The cause of abdominal pain is thought to be due to either poor blood flow from CACS, nerve irritation or combination of both. Compression of the celiac artery may result in the blood flow coming from another abdominal vessel (the superior mesenteric artery) and going to the stomach and liver when a patient eats, known as ‘steal phenomenon’. The treatment options for MALS include surgical laparoscopic or robotic division of MAL, celiac ganglion destruction and bypass surgery.

Conclusion: MALS is diagnosis of exclusion. CT angiography is an excellent modality to rule out various pathologies and diagnose MALS.