Small Intestine: Median Arcuate Ligament Syndrome (MALS)

Median Arcuate Ligament Syndrome (MALS)

Also Known As

  • Celiac Artery Compression Syndrome
  • Celiac Axis Syndrome
  • Dunbar Syndrome

Pathophysiology

  • Median Arcuate Ligament Compresses Celiac Artery
    • Median Arcuate Ligament Traverses the Aorta & Bridges the Diaphragmatic Crura
  • Causes:
    • Abnormally High Origin of Celiac Artery (Most Common)
    • Abnormally Low Median Arcuate Ligament (10%)
    • Celiac Plexus Nerves Can Also Contribute to Compression

Presentation

  • Characteristic Triad:
    • Postprandial Abdominal Pain
    • Weight Loss
    • Epigastric Bruit
  • Other Sx:
    • Nausea & Vomiting
    • Diarrhea

Diagnosis

  • Dx: Duplex US, CTA or MRA
    • Inspiratory & Expiratory Arteriography is Preferred but Often Unable
    • Diagnosis of Exclusion

Treatment

  • ASx: Observation
  • Sx: Celiac Artery Decompression
    • Transect Median Arcuate Ligament & Celiac Ganglion Neurolysis

MALS Diagram; (a) Normal, (b) MALS 1

MALS CTA 2

References

  1. Hongsakul K, Rookkapan S, Sungsiri J, Tubtawee T. A severe case of median arcuate ligament syndrome with successful angioplasty and stenting. Case Rep Vasc Med. 2012;2012:129870. (License: CC BY-3.0)
  2. Divarci E, Celtik U, Dokumcu Z, Celik A, Ergun O. Laparoscopic Treatment of Median Arcuate Ligament Syndrome: A Rare Cause of Chronic Severe Abdominal Pain. J Indian Assoc Pediatr Surg. 2017 Jan-Mar;22(1):48-50. (License: CC BY-NC-SA-3.0)