P5079 - Unlocking Relief: Approach to Alleviating Median Arcuate Ligament Syndrome

Amanda Rigdon, MD, Daniela Carralero-Somoza, MD, Vivian Loveday-Laghi, MD
Lakeland Regional Health, Lakeland, FL

Introduction: Median Arcuate Ligament Syndrome (MALS) is a rare condition with no diagnostic criteria established, resulting in alternative causes of abdominal pain to be excluded. It stands as a perplexing challenge in the medical field, marked by its elusive diagnosis and the scarcity of effective management strategies. This case report explores the intricate web of difficulties surrounding the identification and treatment of this syndrome.

Case Description/Methods: We report a case of a 42-year-old female with a history of abdominoplasty and gastric sleeve s/p reversal, who presented with several hospital admissions for intractable abdominal pain. With each visit, she experienced severe agony, diffuse pain, nausea, & hypertensive urgency. Extensive workup included EGD, antidepressants, proton pump inhibitors, multiple dietary changes, and pain clinic management. Her episodic flares resulted in recurrent vomiting, dehydration, and malnourishment. During numerous admissions, multiple celiac plexus nerve block's were performed, providing transient relief. The fluctuating post-prandial discomfort persisted despite efforts. Vascular causes were eventually considered following a CTA incidentally identified celiac artery compression concerning for median arcuate ligament syndrome. Though rare, MALS emerged as a differential diagnosis for post-bariatric surgery abdominal pain refractory to gastrointestinal evaluation, and warranted consideration.

Discussion: It's hypothesized that rapid weight loss after bariatric surgery leads to loss of the fat pad around vessels. This reduces protection for the celiac artery, making it more susceptible to compression by the median arcuate ligament. Patients coming with excruciating abdominal pain somehow unexplained by imaging and history of abdominal surgery should ignite suspicion. Delays in diagnosis lead to under care of patients. Accurate identification will lead to tailored treatment strategies.

MALS warrants inclusion in differential diagnoses of chronic postprandial abdominal pain. Increased awareness of MALS can prompt vascular imaging, enabling earlier detection. Celiac plexus ablation provide's substantial temporary pain relief. Though not curative, and pain often recurs within months, this may bridge patients to surgical interventions such as celiac artery decompression. More research on durability is needed to determine the utility of plexus ablation alongside decompression surgery in a multimodal approach targeting the abdominal pain of MALS.



Disclosures:


Amanda Rigdon, MD, Daniela Carralero-Somoza, MD, Vivian Loveday-Laghi, MD. P5079 - Unlocking Relief: Approach to Alleviating Median Arcuate Ligament Syndrome, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.