Materiały źródłowe

• #1 Overview of Median Arcuate Ligament Syndrome: A Narrative Review

  https://pmc.ncbi.nlm.nih.gov/articles/PMC10629207/

  Median arcuate ligament syndrome (MALS) is a rare disorder caused primarily by compression of the celiac trunk by the median arcuate ligament (MAL). […] The MALS diagnosis is one of exclusion, as the disorder has no specific diagnostic criteria. Imaging modalities are often utilized to assist in making the diagnosis, such as ultrasound, computed tomography angiography (CTA), and magnetic resonance angiography (MRA). […] The diagnosis of MALS is a diagnosis of exclusion. Various imaging modalities may be utilized to rule out other diseases, such as CT and ultrasound. […] Imaging plays a key role in the diagnosis of MALS. There are multiple modalities to aid in this diagnosis, though some have proven to be more useful than others. The imaging modalities that may be used include computed tomography angiography (CTA), doppler ultrasound, and magnetic resonance angiography (MRA). […] When determining the best technique to assess for MALS in patients, a multifactorial approach should be considered. Additional factors that should be considered when making a diagnosis of MALS are patient history, age, and symptoms.

• #2 Median arcuate ligament syndrome – Wikipedia

  https://en.wikipedia.org/wiki/Median_arcuate_ligament_syndrome

  Median arcuate ligament syndrome is a diagnosis of exclusion. That is, the diagnosis of MALS is generally considered only after patients have undergone an extensive evaluation of their gastrointestinal tract including upper endoscopy, colonoscopy, and evaluation for gallbladder disease and gastroesophageal reflux disease (GERD). […] The diagnosis of MALS relies on a combination of clinical features and findings on medical imaging. Clinical features include those signs and symptoms mentioned above; classically, MALS involves a triad of abdominal pain after eating, weight loss, and an abdominal bruit, although the classic triad is found in only a minority of individuals that carry a MALS diagnosis. […] Diagnostic imaging for MALS is divided into screening and confirmatory tests. A reasonable screening test for patients with suspected MALS is duplex ultrasonography to measure blood flow through the celiac artery.

• #3 Median Arcuate Ligament Syndrome

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8917964/

  Median arcuate ligament syndrome (MALS) is uncommon and often difficult to diagnose due to the vague presenting symptoms of abdominal pain, weight loss, and early satiety. […] Diagnosis can be confirmed with CT and/or angiography. […] The gold standard for diagnosis of MALS is three-dimensional computed tomography angiography (CTA), which can determine the degree of compression and identify potential collateral vessels from the superior mesenteric artery. […] Treatment of MALS is surgical decompression with or without celiac plexus block. […] The goal of surgery is to divide and excise the fibers of the median arcuate ligament that stretch across the celiac trunk. […] If symptoms of nausea, vomiting, postprandial pain, and weight loss persist even after laparoscopic ligament release, revascularization of the celiac artery by either endovascular stenting or bypass can be considered as secondary options. […] This case presentation highlights the importance of considering MALS in the differential diagnosis for patients presenting with chronic abdominal pain and symptoms worrisome for malignancy, including weight loss and early satiety.

• #4 MALS Diagnosis & Treatment | Contact Us | Birmingham HPB

  https://birminghamhpbclinic.co.uk/median-arcuate-ligament-syndrome-mals-diagnosis-treatment/

  Diagnosing MALS is a complex process that necessitates a thorough evaluation. The following diagnostic techniques are typically employed: […] Comprehensive medical history: The journey to diagnosis begins with a detailed medical history. Patients are encouraged to provide a comprehensive account of their symptoms, their duration, and any factors that exacerbate or alleviate their discomfort. […] Physical examination: A physical examination may reveal tenderness in the abdominal area or, sometimes, the presence of an abdominal bruit, which is an abnormal sound that can indicate vascular abnormalities. […] Imaging studies: Radiological tests are essential for confirming MALS. These include: […] CT angiography (CTA): This non-invasive imaging technique provides highly detailed images of the blood vessels, aiding in the identification of any compression or narrowing of the celiac artery.

• #5 Median arcuate ligament syndrome (MALS) – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/median-arcuate-ligament-syndrome-mals/diagnosis-treatment/drc-20505007

  To diagnose median arcuate ligament syndrome, also called MALS, a healthcare professional examines you and asks questions about your symptoms. The healthcare professional may hear a whooshing sound, called a bruit, when listening to your stomach with a stethoscope. The sound may occur when a blood vessel is narrowed. […] Tests to diagnose median arcuate ligament syndrome may include: […] Ultrasound of the abdomen. This test uses sound waves to see how blood is flowing through the blood vessels. It can show if the celiac artery is compressed, especially when breathing in and out deeply. […] Abdominal computerized tomography (CT). A CT scan uses X-rays to create cross-sectional images of parts of the body. This test can show whether the celiac artery is narrowed or blocked. […] Celiac plexus block. Numbing medicine is injected into the nerves that sit on each side of the celiac artery. The numbing medicine lasts for several hours. This treatment mimics what happens during surgery to treat MALS. This test is often used to learn who may do well with MALS surgery.

• #6 MALS | National MALS Foundation

  https://www.malsfoundation.org/what-is-mals

  A History Physical (HP) are important tools helpful in the diagnosis process. Physical examination may activate tenderness in the epigastric region when palpated. The Doctor may hear a whooshing sound known as an abdominal bruit or thrill in the same epigastric area along with listening for bowel sounds. Observations may include weight loss and malnutrition may be evident. Once MALS is suspected, a diagnostic workup is initiated to include various tests indicative of a diagnosis of MALS and rule out cardiovascular and gastrointestinal issues.

• #7 Median arcuate ligament syndrome (MALS) // Middlesex Health

  https://middlesexhealth.org/learning-center/diseases-and-conditions/median-arcuate-ligament-syndrome-mals

  To diagnose median arcuate ligament syndrome, also called MALS, a healthcare professional examines you and asks questions about your symptoms. The healthcare professional may hear a whooshing sound, called a bruit, when listening to your stomach with a stethoscope. The sound may occur when a blood vessel is narrowed. […] Because many conditions can cause stomach pain, you usually have many tests to find the cause and rule out other possible conditions. […] Tests to diagnose median arcuate ligament syndrome may include: Blood tests. These tests are done to check for health conditions involving the liver, pancreas, kidneys and other parts of the body. A complete blood cell count shows the level of white and red blood cells. A high white blood cell count can mean there’s an infection. […] Ultrasound of the abdomen. This test uses sound waves to see how blood is flowing through the blood vessels. It can show if the celiac artery is compressed, especially when breathing in and out deeply.

• #7 Median arcuate ligament syndrome (MALS) // Middlesex Health

  https://middlesexhealth.org/learning-center/diseases-and-conditions/median-arcuate-ligament-syndrome-mals

  Upper endoscopy. This procedure also is called esophagogastroduodenoscopy, known as an EGD. It’s done to see the esophagus, stomach and upper part of the small intestine. During an EGD, a doctor guides a long, flexible tube with a camera on the end down the throat after applying numbing medicine. Also, tissue samples, called biopsies, can be removed for lab tests. […] Gastric emptying studies. Pressure on the celiac artery can slow the rate of stomach emptying. These tests can show how fast the stomach empties its contents. Slow or delayed emptying may be caused by other medical conditions. […] Magnetic resonance imaging (MRI). An MRI uses magnets and radio waves to make detailed images of the body area being studied. Sometimes, dye, called contrast, is given by IV. The dye show how blood moves through the arteries. This is called a magnetic resonance angiogram, also known as an MRA.

• #8 MALS: Median Arcuate Ligament Syndrome Overview

  https://www.verywellhealth.com/mals-median-arcuate-ligament-syndrome-4691027

  Median arcuate ligament syndrome is rare and often difficult to diagnose. […] MALS is difficult to diagnose and is only identified (with the help of imaging) when other possible causes of symptoms are ruled out. […] Diagnosis of MALS is usually made by eliminating other diseases that cause these symptoms. This makes it what is known as a diagnosis of exclusion. […] Individuals with MALS often undergo a significant number of medical tests before a diagnosis is made. […] Once MALS is suspected, vascular imaging is necessary to confirm or rule out the diagnosis. […] If a mesenteric duplex ultrasound performed during deep expiration suggests you might have MALS, follow-up tests such as a CT scan or MRI angiogram can help your healthcare provider to confirm this diagnosis. […] When these tests fail to result in a diagnosis, three classic symptoms may lead your healthcare provider to consider MALS. They include: Unintentional weight loss, Abdominal bruit, Abdominal pain following meals.

• #8 MALS: Median Arcuate Ligament Syndrome Overview

  https://www.verywellhealth.com/mals-median-arcuate-ligament-syndrome-4691027

  A celiac plexus block involves the injection of a local anesthetic (via needle) into the celiac plexus nerve bundle. […] If you experience pain relief after the nerves have been blocked this may be a good indication that you not only have MALS but also that you would benefit from corrective surgery. […] Studies show that approximately 60% to 80% of patients who underwent celiac artery decompression experienced relief of their symptoms following surgery. […] It typically takes time and many different tests to rule out other possible causes of symptoms and come to a MALS diagnosis.

• #9 Median arcuate ligament syndrome (MALS) – Augusta HealthSearchClose SearchSearch IconSearch IconClose Search IconMobile Menu IconMobile Menu Close IconInstagramFacebookTwitterYoutube

  https://www.augustahealth.com/disease/median-arcuate-ligament-syndrome-mals/

  Median arcuate ligament syndrome (MALS) occurs when the arc-shaped band of tissue in the chest area (median arcuate ligament) presses on, or traps, the artery that supplies blood to the organs in your upper abdomen (celiac artery). […] The causes and diagnosis of MALS has been a subject of controversy. […] There’s no specific test to diagnose MALS. Your doctor will carefully examine you and ask questions about your symptoms and health history. The physical exam is often normal in people with MALS. Bloodwork and imaging tests help your doctor rule out other causes of stomach pain. […] Tests used to rule out other conditions and diagnose MALS may include: Blood tests. Comprehensive blood tests are done to check for problems with your liver, pancreas, kidneys and other parts of the body.

• #10 MALS Awareness – Median Arcuate Ligament Syndrome | MALS Awareness

  https://malsawareness.com/mals

  MALS, which stands for Median Arcuate Ligament Syndrome, is a congenital anatomical anomaly. […] The two most common ways to diagnose MALS are an abdominal CT scan with contrast and a doppler ultrasound of the celiac artery. […] To find MALS on a CT scan, it is helpful (though not entirely necessary) for the patient to hold an exhale position, as it makes the characteristic hook shape of the celiac artery more apparent. […] Because a compression on the celiac artery can cause a change in blood flow velocities, a doppler ultrasound can also be used to diagnose MALS. […] Many patients have already had the testing necessary to diagnose MALS, though they and their doctors may be unaware–and yet most patients endure pain for years while wading through numerous tests and misdiagnoses. Raising awareness for this diagnosis is imperative if doctors hope to help patients restore their quality of life.

• #11 Median arcuate ligament syndrome (MALS) | Health Library | Memorial Health System

  https://www.mhsystem.org/health-library/con-20459603/

  Median arcuate ligament syndrome, also called MALS, happens when the band of tissue in the upper belly area presses on the artery that sends blood to the stomach, spleen and liver. This tissue is called the median arcuate ligament. The artery is called the celiac artery. […] To diagnose median arcuate ligament syndrome, also called MALS, a healthcare professional examines you and asks questions about your symptoms. The healthcare professional may hear a whooshing sound, called a bruit, when listening to your stomach with a stethoscope. The sound may occur when a blood vessel is narrowed. […] Tests to diagnose median arcuate ligament syndrome may include: Blood tests. These tests are done to check for health conditions involving the liver, pancreas, kidneys and other parts of the body. A complete blood cell count shows the level of white and red blood cells. A high white blood cell count can mean there’s an infection.

• #11 Median arcuate ligament syndrome (MALS) | Health Library | Memorial Health System

  https://www.mhsystem.org/health-library/con-20459603/

  Ultrasound of the abdomen. This test uses sound waves to see how blood is flowing through the blood vessels. It can show if the celiac artery is compressed, especially when breathing in and out deeply. […] Upper endoscopy. This procedure also is called esophagogastroduodenoscopy, known as an EGD. It’s done to see the esophagus, stomach and upper part of the small intestine. During an EGD, a doctor guides a long, flexible tube with a camera on the end down the throat after applying numbing medicine. Also, tissue samples, called biopsies, can be removed for lab tests. […] Gastric emptying studies. Pressure on the celiac artery can slow the rate of stomach emptying. These tests can show how fast the stomach empties its contents. Slow or delayed emptying may be caused by other medical conditions.

• #12 Median arcuate ligament syndrome: When to consider the diagnosis and management options

  https://www1.racgp.org.au/ajgp/2024/supplement-december/median-arcuate-ligament-syndrome

  Median arcuate ligament syndrome (MALS) occurs due to extrinsic compression of the coeliac plexus, leading to postprandial and exercise-induced epigastric pain, nausea, vomiting, food fear and weight loss. […] Diagnosis can be challenging as up to 25% of the population have radiological compression. However, only 1% of the population have corresponding symptoms. […] The duration between the onset of symptoms and diagnosis of MALS can extend up to years. […] MALS does not have universally accepted diagnostic criteria. However, it is a diagnosis that remains one of relative exclusion and is typically the result of extensive investigations to exclude more common, alternative causes of abdominal pain. […] Recommended work-up includes targeted blood tests (full blood count and liver function, renal function and lipase/amylase tests), urinary culture, biliary ultrasound, and upper and lower endoscopies with Helicobacter pylori testing and food allergy testing, including coeliac disease.

• #12 Median arcuate ligament syndrome: When to consider the diagnosis and management options

  https://www1.racgp.org.au/ajgp/2024/supplement-december/median-arcuate-ligament-syndrome

  If the above investigations are normal, along with a finding of coeliac artery compression, a diagnosis of MALS should be considered and the patient would benefit from multidisciplinary input, including from a gastroenterologist and a vascular surgeon. […] Evidence of coeliac artery compression alone on CT is not diagnostic of MALS. […] Further diagnostic tests are still being evaluated, such as gastric exercise tonometry. If the gastric fluid is more acidic post exercise, this suggests significant coeliac artery compression or ischaemia. […] Coeliac plexus block is a non-surgical option for relief from MALS that can also aide as a diagnostic test. […] The surgical treatment of MALS includes decompressing the artery and performing a coeliac ganglionectomy. […] MALS is a rare cause of abdominal pain that lacks defined diagnostic criteria.

• #12 Median arcuate ligament syndrome: When to consider the diagnosis and management options

  https://www1.racgp.org.au/ajgp/2024/supplement-december/median-arcuate-ligament-syndrome

  Testing in the primary care setting, as outlined in this article, is recommended to exclude other causes of abdominal pain and allow for subsequent referral. […] Due to the challenges in both diagnosis and treatment of MALS, multidisciplinary care involving general practitioners along with subspecialists is vital for successful outcomes.

• #13 Median arcuate ligament syndrome (MALS) – Augusta HealthSearchClose SearchSearch IconSearch IconClose Search IconMobile Menu IconMobile Menu Close IconInstagramFacebookTwitterYoutube

  https://www.augustahealth.com/disease/median-arcuate-ligament-syndrome-mals/

  Ultrasound of your abdomen. This noninvasive test uses high-frequency sound waves to determine how blood is flowing through your blood vessels. […] Computerized tomography (CT) of the abdomen. CT uses X-rays to create 3D images of the body area examined. An abdominal CT scan can show if the celiac artery is narrowed or blocked. If the diagnosis is still unclear after other imaging tests are done, your doctor may inject a dye into a blood vessel to highlight blood flow in your arteries and veins (CT angiogram).

• #14 Median arcuate ligament syndrome – Wikipedia

  https://en.wikipedia.org/wiki/Median_arcuate_ligament_syndrome

  Peak systolic velocities greater than 200 cm/s are suggestive of celiac artery stenosis associated with MALS. […] Further evaluation and confirmation can be obtained via angiography to investigate the anatomy of the celiac artery. […] The findings of focal narrowing of the proximal celiac artery with poststenotic dilatation, indentation on the superior aspect of the celiac artery, and a hook-shaped contour of the celiac artery support a diagnosis of MALS. […] The hook-shaped contour of the celiac artery is characteristic of the anatomy in MALS and helps distinguish it from other causes of celiac artery stenosis such as atherosclerosis.

• #15 Median Arcuate Ligament Syndrome | Applied Radiology

  https://appliedradiology.com/articles/median-arcuate-ligament-syndrome

  A peak systolic velocity of 200cm/s within the artery during expiration has a sensitivity of 75% and a specificity of 89% for MALS. […] Computed tomography scans with sagittal reconstruction are also useful in diagnosing MALS. […] Classic findings are narrowing and inferior displacement of the proximal celiac artery, forming a J shape or hooking of the artery. […] Management of MALS revolves around decompressing the celiac artery and the celiac plexus to restore blood flow and alleviate pain. […] More recently, laparoscopic surgery has become the preferred approach to treatment, as the procedure is minimally invasive, faster, and requires a shorter hospital stay. […] Median arcuate ligament syndrome is important to keep in mind when presented with patient complaints of generalized abdominal symptoms, as it can lead to debilitating signs and symptoms, including marked weight loss. […] Obtaining Doppler ultrasound and sagittal CT scans at the end of inspiration is the most effective means of visualizing celiac artery compression.

• #15 Median Arcuate Ligament Syndrome | Applied Radiology

  https://appliedradiology.com/articles/median-arcuate-ligament-syndrome

  An adolescent with a two-year history of abdominal pain and vomiting after meals presented with diffuse abdominal tenderness on palpation. […] The diagnostic workup consisted of a normal upper gastrointestinal series and esophagogastroduodenoscopy, as well as a celiac nerve block which did not relieve the postprandial pain. […] Median arcuate ligament syndrome. […] Other common etiologies such as GERD, gastritis, and Crohn disease must first be excluded before MALS can be diagnosed. Patients in suspect cases will undergo Doppler ultrasound and CT examination. […] In those with MALS, Doppler ultrasound of the celiac artery will reveal lower blood flow, suggesting celiac artery stenosis. […] The PSV must be obtained at end inspiration, as in 13-51% of healthy individuals the celiac artery is compressed during expiration, although this is clinically insignificant.

• #16

  https://journals.lww.com/acgcr/fulltext/2021/10000/often_overlooked_diagnosis__median_arcuate.5.aspx

  Median arcuate ligament syndrome occurs when the celiac artery and/or the celiac plexus nerves is compressed by the median arcuate ligament during expiration causing a variety of gastrointestinal symptoms. […] Symptomatology, computed tomography angiography, and abdominal ultrasound Doppler were consistent with celiac artery compression syndrome. […] The diagnosis of MALS significantly relies on reviewing the patient’s symptoms, medical history, and correlating imaging findings with patient symptoms and resolution of symptoms with treatment. […] It is crucial that once MALS is considered, patients undergo relevant diagnostic evaluation. […] A diagnosis of MALS is demonstrated when mesenteric duplex ultrasound shows increased blood flow velocities of greater than 200 cm/s in the celiac artery and end diastolic velocity greater than 55 cm/s.

• #16

  https://journals.lww.com/acgcr/fulltext/2021/10000/often_overlooked_diagnosis__median_arcuate.5.aspx

  A high index of suspicion is needed among patients with persistent symptoms despite adequate treatment of other more common abdominal disease because MALS can present as a mimicker of more common abdominal disease. […] The diagnosis of MALS can be further complicated because there is a large proportion of patients who have celiac artery compression, but do not present with symptoms. […] Previous studies have demonstrated that certain patient characteristics such as abdominal pain after eating, patients between 40 and 60 years of age, and weight loss of 20 pounds or more indicate a better prognosis after surgical intervention and these characteristics should help determine who needs surgery. […] MALS is an often-overlooked diagnosis, and unfortunately, most patients have had protracted workup and sometimes even surgical procedures before the diagnosis of MALS is even considered.

• #17 Median Arcuate Ligament Syndrome: From Diagnosis to Multidisciplinary Management—A Narrative Review

  https://www.mdpi.com/2813-2475/4/1/11

  In MALS diagnostics DUS is used to measure parameters such as end-expiratory upturn-angle of the celiac trunk and inspiratory/expiratory peak systolic velocity. […] Another diagnostic modality used to evaluate patients with suspected MALS is CTA, which allows for meticulous assessment of celiac trunk and MAL anatomy. […] To date, MAL thickening has been considered significant when thickness is greater than 4 mm. However, recent studies indicate a mean MAL thickness at CTA in men and women of 8.4 ± 2.52 mm and 6.9 ± 2.41 mm, respectively. […] CE-MRA can be considered as a potential alternative to CTA in patients who should avoid exposure to radiation or have allergy for contrast used in CTA.

• #18 Diagnosis of Median Arcuate Ligament Syndrome on Multidetector Computed Tomography | Göya | Journal of Medical Cases

  https://www.journalmc.org/index.php/JMC/article/view/1384/820

  In this paper, we aimed to present three cases that were diagnosed with median arcuate ligament syndrome on multidetector computed tomography (MDCT). […] Celiac artery compression may be investigated with Doppler US, conventional angiography, CT angiography, and magnetic resonance angiography. Doppler US has been reported to have a high sensitivity for the diagnosis of the MALS and has been proposed to be the method of choice for diagnosing the MALS. The gold standard diagnostic method is conventional angiography, which should be performed during both inspiration and expiration, in the lateral position. The images that are not taken in the lateral position may fail to visualize the lesion and the MAL. However, recent implementation of MDCT has enabled the production of fast, thin-slice, multiplanar, reformatted and 3D angiographic images. Also, high-resolution images can be obtained for the aorta and its branches and also for the mesenteric vascular structures. In our study with 64-slice CT, the multiplanar reformatted 3D angiographic images perfectly demonstrated the vascular anatomy and compression without any need for conventional angiography, which is a more invasive technique. In patients with MAL syndrome, CT angiography demonstrates a characteristic focal narrowing in the proximal celiac axis. The focal narrowing has a characteristic hooked appearance, which can be useful in distinguishing this condition from other causes of celiac artery stenosis such as atherosclerosis. The features of the MALS include poststenotic dilatation and collateral vascular vessels. […] We conclude that the MDCT is a minimally invasive and useful diagnostic tool for the diagnosis of MAL syndrome, which can be used as an alternative to the conventional invasive angiography.

• #19 :: KJR :: Korean Journal of Radiology

  https://www.kjronline.org/DOIx.php?id=10.3348/kjr.2014.15.4.439

  Diagnosis of MALS was made if a greater than 2-fold acceleration of peak systolic flow in the celiac artery compared to the abdominal aorta or a peak systolic velocity greater than 200 cm/s was measured in the mid position and if a variation of flow velocity occurred during respiration. […] The CT findings characteristic of MALS may not be appreciated on axial images alone. […] Additional diagnostic techniques that may be used to aid in the diagnosis of MALS include magnetic resonance angiography (MRA) and direct catheter angiography. […] A definite diagnosis of MALS can be achieved by lateral aortography of the visceral aorta and its branches during inspiration and expiration. […] The presence of poststenotic dilatation and hypertrophy of the pancreaticoduodenal arcades (which act as collateral vessels from the celiac artery) imply a more severe degree of stenosis and hemodynamic significance.

• #19 :: KJR :: Korean Journal of Radiology

  https://www.kjronline.org/DOIx.php?id=10.3348/kjr.2014.15.4.439

  Median arcuate ligament syndrome is an anatomic and clinical entity characterized by dynamic compression of the proximal celiac artery by the median arcuate ligament, which leads to postprandial epigastric pain, vomiting, and weight loss. […] Median arcuate ligament syndrome (also referred to as celiac artery compression syndrome) is often diagnosed when idiopathic, episodic abdominal pain is associated with dynamic compression of the proximal celiac artery by fibers of the median arcuate ligament. […] The diagnosis of MALS is mainly based on the exclusion of other intestinal disorders but once suspected, imaging techniques including Doppler ultrasound, computed tomography, magnetic resonance imaging and selective catheter angiography can be used to identify the abnormality. […] A reasonable screening test for the suspected patients is duplex ultrasonography that measure the rate of blood flow, enabling quantitative evaluation of celiac artery flow on inspiration and expiration, and comparison of flow rate before, during and after surgery.

• #20 Median Arcuate Ligament Syndrome Clinical Presentation, Pathophysiology, and Management: Description of Four Cases

  https://www.mdpi.com/2624-5647/3/1/5

  MALS is a diagnosis that should be considered in patients with chronic post-prandial abdominal pain in the absence of any objective findings, as well as lack of response to all standard empiric therapies for acid-related conditions, irritable bowel syndrome, and gastroparesis. […] The gold standard for diagnosing MALS is lateral view aortic angiography, which shows more than 50% narrowing in the origin of the celiac artery, with or without distal dilation, with improvement during inspiration. […] Diagnosis relies on the utilization of imaging modalities like angiogram and color Doppler ultrasound with the respiratory variation of celiac blood flow.

• #21 Median arcuate ligament syndrome (Dunbar syndrome) – Iqbal – Cardiovascular Diagnosis and Therapy

  https://cdt.amegroups.org/article/view/67298/html

  Median arcuate ligament syndrome (MALS) is a rare condition which is due to the compression of celiac trunk by low riding of fibrous attachments of median arcuate ligament and diaphragmatic crura. Technically, MALS is a diagnosis of exclusion, consisting of vague symptoms comprising of postprandial epigastric pain, nausea, vomiting and unexplained weight loss. Different imaging modalities like Doppler ultrasound, computed tomography, magnetic resonance imaging and mesenteric angiogram are helpful to demonstrate celiac axis compression. […] MALS is usually a diagnosis of exclusion. It generally mimics abdominal disorders. Duplex ultrasonography can be a good initial screening tool for celiac artery compression due to its lack of ionizing radiation and contrast need. However, it is operator dependent and needs experienced operator to evaluate and show the changes.

• #21 Median arcuate ligament syndrome (Dunbar syndrome) – Iqbal – Cardiovascular Diagnosis and Therapy

  https://cdt.amegroups.org/article/view/67298/html

  Computed tomography angiogram (CTA) helps in the diagnosis allowing three-dimensional visualization of compressed celiac artery. CTA has high resolution and can show changes like post stenotic dilatation; however, it involves ionizing radiation and needs contrast which can be a limitation in patients with renal dysfunction. […] Conventional angiography is the gold standard to show dynamic compression. […] The treatment of MALS aims at decompression of celiac artery to establish adequate blood flow and pain management by neurolysis. Surgery is the definitive management. […] The role of intervention radiology is emerging in the treatment of MALS, though its outcomes are not promising. The use of percutaneous transluminal angioplasty (PTA) can be used as an adjuvant therapy prior to surgery.

• #21 Median arcuate ligament syndrome (Dunbar syndrome) – Iqbal – Cardiovascular Diagnosis and Therapy

  https://cdt.amegroups.org/article/view/67298/html

  The diagnosis is difficult and needs a high grade of suspicion with supportive imaging findings. The treatment is aimed at relieving the symptoms with open or laparoscopic surgery with PTA and stenting as adjuvant to robotic ligament release and celiac neurolysis. However, further definitive studies are needed to address the pathophysiology, better diagnose and devise minimally invasive treatment for this entity.

• #22

  https://www.tropicalgastro.com/printerfriendly.aspx?id=2957

  Median arcuate ligament syndrome (MALS) is a condition characterized by chronic, recurrent abdominal pain due to compression of the celiac artery by the median arcuate ligament of the diaphragm. […] Based upon diagnostic studies using computed tomography (CT) of the abdomen or arteriography, the incidence of asymptomatic celiac artery stenosis appears to be approximately 7%. […] CT scan of the abdomen revealed tight stenosis of the celiac artery at its origin due to indentation by median arcuate ligament suggestive of MALS. […] The clinical significance of this finding was further confirmed by Doppler ultrasonography which revealed significant difference in the celiac artery peak systolic and end diastolic velocities during inspiration and expiration. […] A definitive diagnosis of MALS requires vascular imaging to confirm compression of the celiac artery by the median arcuate ligament (duplex ultrasound combined with advanced vascular imaging), preferably with respiratory maneuvers. […] Conventional angiography and / or recently multi-detector CT angiography is the gold standard for the diagnosis MALS. […] The key to successful outcomes is careful selection of patients for treatment. […] Diagnosis can be confirmed by doppler ultrasonography and/or CT angiography.

• #23 UT Physicians | Median arcuate ligament syndrome (MALS)

  https://www.utphysicians.com/median-arcuate-ligament-syndrome/

  The compression of the celiac artery is a key component of the diagnosis of MALS. This can be determined using noninvasive vascular imaging such as duplex arterial ultrasound, computed tomography angiography (CTA), or magnetic resonance angiography (MRA). […] The surgical consultation with an expert on MALS treatment is needed once the diagnosis is contemplated. […] The term neurolysis is used to describe the removal of nerve and ganglionic tissue that surrounds the artery in the front, sides, and back. […] The main advantages of the open surgical approach rely on the safety of surgical dissection under direct vision and ability to handle any small tear or areas of bleeding. This approach also allows thorough and complete circumferential release of the artery, including the tissue that lies behind the celiac artery.

• #23 UT Physicians | Median arcuate ligament syndrome (MALS)

  https://www.utphysicians.com/median-arcuate-ligament-syndrome/

  Median arcuate ligament syndrome (MALS) is an uncommon condition that predominantly affects young individuals due to excessive compression of the celiac artery, the first large branch of the abdominal aorta located near the median arcuate ligament and celiac ganglion. The diagnosis of MALS can be difficult because most patients present with nonspecific upper abdominal pain and because compression of the artery itself is not sufficient to determine cause and effect. […] The evaluation includes several gastroenterology tests including upper endoscopy and colonoscopy, motility studies, gastric emptying tests, and serology studies. Not all patients require all the above-mentioned tests, but an expert opinion of a gastroenterologist is critical to guide the diagnostic work-up and to establish that MALS is the most likely cause of the pain.

• #23 UT Physicians | Median arcuate ligament syndrome (MALS)

  https://www.utphysicians.com/median-arcuate-ligament-syndrome/

  Most studies evaluating the outcomes of MALS are retrospective reviews of single center experiences spanning many years and having a relatively small number of patients. For this reason, the level of scientific evidence is low and there is a great deal of discussion among experts with respect to best practices, the role of celiac ganglion block, and superiority of open surgical or laparoscopic approach.

• #24 A case report on median arcuate ligament syndrome: Need for a high index of suspicion – Medicine India

  https://medindiajournal.com/a-case-report-on-median-arcuate-ligament-syndrome-need-for-a-high-index-of-suspicion/

  The Median Arcuate Ligament Syndrome (MALS) is a rare clinical entity occurring due to abnormally low insertion of the ligament across the origin of the coeliac axis resulting in varying degrees of celiac artery compression. […] Its diagnosis requires a high index of clinical suspicion coupled with appropriate imaging. […] The patient was suspected to have MALS by using ultrasound and color Doppler imaging. […] These findings were confirmed using Computed tomography angiography (CTA) of the abdomen. […] A combination of a high index of suspicion with the use of appropriate imaging techniques can clinch this diagnosis. […] The best method of the evaluation of this entity is CT with three-dimensional reconstruction where the low insertion of the median arcuate ligament, the high origin of the celiac trunk, and the hook or J-shaped indentation on the celiac artery, all can be demonstrated.

• #25 Vascular – CT Protocols – CTisus.com CT Scanning

  https://ctisus.com/protocol/vascular/49834

  Please note that CT studies are best evaluated in the end-inspiratory phase. Since MAL is attached to the diaphragm, movement occurs with respiration, and true compression can be evaluated in the end-inspiratory phase. Isolated compression of the celiac axis in expiration can be observed in 13%-50% of healthy individuals and can be clinically insignificant. Few of these patients would have clinical symptoms due to hemodynamic compromise. In a retrospective study, Heo et al. showed that 87% of patients with classical imaging findings of MALS incidentally detected on CT had no symptoms. […] Dynamic CT examination may also be performed in both deep inspiration and expiration in order to evaluate the dynamic modifications in celiac artery diameter. CT imaging should include the early arterial phase acquired in deep expiration in order to increase the proximal celiac trunk compression by the median arcuate ligament, followed by the portal venous phase in deep inspiration. Sagittal and coronal images should be included for optimal visualization of the celiac artery. The proximal narrowing of the celiac trunk can be better depicted on sagittal CT reconstructions, demonstrating a focal indentation on the superior surface of the vessel with a typical hooked appearance, in the absence of atherosclerotic plaques or other causes of extrinsic compression.

• #26 Diagnosis

  https://med.uth.edu/cvs/patient-care/conditionsandprocedures/median-arcuate-ligament-syndrome-mals/diagnosis-mals/

  In order to diagnose MALS, patients often undergo a multidisciplinary evaluation with several specialties including gastroenterology, vascular surgery, general surgery, cardiology, anesthesia pain management, interventional radiology, and psychological assessment. […] The compression of the celiac artery is a key component of the diagnosis of MALS. This can be determined using noninvasive vascular imaging such as duplex arterial ultrasound, computed tomography angiography (CTA), or magnetic resonance angiography (MRA). […] A frequent test is the celiac ganglion block, which involves local injection of anesthetic and/or steroids in the location of the celiac ganglion and adjacent nerves. The test may be used as a surrogate or therapeutic trial to anticipate the effects of surgical treatment of MALS, which involves release or removal of the arcuate ligament muscle and fibers as well as the removal of the adjacent ganglion tissue (ganglionectomy). […] Diagnostic tests: Imaging of the celiac artery compression.

• #27 MALS: Causes, Symptoms & Treatment | Dr. Joshua Tierney

  https://www.drjoshuatierney.com/conditions/vascular/mals/

  Provides real-time assessment of blood flow and can help visualize the artery and celiac axis compression. […] Often used for children or young adults to avoid exposure to ionizing radiation. […] This procedure may be used if initial imaging tests are inconclusive, allowing for direct visualization of the blood vessels and confirming the presence of arterial compression. […] Effective management of MALS often involves a team of specialists, including gastroenterologists, vascular surgeons, and pain management experts, working together to provide comprehensive and personalized care. This collaborative approach is critical for the management of median arcuate ligament syndrome and the surgical treatment of MALS.

• #28 Median Arcuate Ligament Syndrome – Practical Gastro

  https://practicalgastro.com/2015/02/05/median-arcuate-ligament-syndrome/

  The treatment is surgical release of the median arcuate ligament to achieve decompression of the celiac artery and the celiac plexus. […] MALS is a diagnosis of exclusion to be considered when the subjective presentation of upper abdominal pain is dominant in the absence of any objective findings. […] Imaging is required to confirm the celiac artery compression by the MAL and other imaging is necessary to exclude any other causes of the patients symptoms. […] The diagnosis can be made through different imaging modalities including duplex ultrasound, CT angiography, magnetic resonance angiography, and arteriography. […] The gold standard for diagnosis of MALS is the lateral view of aortic angiography. […] When the diagnosis is confirmed with imaging in patients with persistent and unexplained upper abdominal pain by evidence of celiac artery compression, there is no medical therapy.

• #29 Median Arcuate Ligament Syndrome | Top Diagnosis & MALS Surgery Near You – The Vascular Experts

  https://thevascularexperts.com/median-arcuate-ligament-syndrome/

  MALS is a congenital anatomic anomaly, meaning it is a structural aberrance present at the time of birth. […] Most doctors dont know about it, so MALS is underdiagnosed. Differential diagnosis for epigastric pain include gastroparesis, eating disorders, IBS, or gallbladder issues. […] Because MALS patients present with gastrointestinal symptoms, they often go through a battery of GI tests, including EGDs, gastric emptying tests, and colonoscopies. […] The anatomy for MALS can be seen on an abdominal CT scan. A mesenteric duplex or MRA can also be used, although these are less specific tests. Other diagnostic criteria required for diagnosis include physical exam findings consistent with inflamed celiac ganglion, and celiac ganglion block to rule in neurogenic cause of pain. […] Tests necessary to diagnose MALS include Abdominal CT with Intravenous Contrast, Physical Exam, and Celiac Ganglion Block.

• #30 Median Arcuate Ligament Syndrome – MALS Awareness | MALS Awareness

  https://malsawareness.com/who-we-are

  The block was performed on 2/16/2017. […] The celiac plexus block did not give me any relief the day of the procedure. […] I consulted with a local pain management doctor who was willing to work with me. […] My surgery was a success and Dr. Hsu confirmed that my celiac plexus nerves were indeed inflamed. […] The MRA showed 50% stenosis with a hook like appearance of the celiac artery… suspicious for median arcuate ligament syndrome. […] It was confirmed median arcuate ligament syndrome! […] The only treatment – surgery. […] I had surgery April 25th, 2017. […] My GI issues have been completely resolved! […] I know now that I had MALS, and that my pain was not in my head, because that pain is now gone for the first time in my life. MALS surgery saved me, and I will never take a moment of Life 2.0 for granted!

• #31 Median Arcuate Ligament Syndrome (MALS) | University Hospitals | University Hospitals

  https://www.uhhospitals.org/services/heart-and-vascular-services/conditions-and-treatments/vascular-disease/median-arcuate-ligament-syndrome

  Median arcuate ligament syndrome (MALS) is a condition in which a ligament in the lower part of the chest, the median arcuate ligament, sits lower than normal. […] Diagnosis of Median Arcuate Ligament Syndrome (MALS) Because the symptoms of MALS are similar to other stomach conditions, diagnosis can be a long process, with some patients waiting years for a positive diagnosis. […] If other conditions are ruled out and MALS is still suspected, your healthcare provider typically will order an ultrasound as the next step. […] Following an ultrasound, a CT scan is usually done to map the anatomy and help with surgical planning. […] The last diagnostic step is usually a celiac plexus nerve block, a procedure performed under fluoroscopy guidance. […] Other tests that may be used to diagnose MALS include: Magnetic resonance imaging (MRI)/magnetic resonance angiogram (MRA): An MRI test uses radio waves and powerful magnets to produce detailed images of the body. […] Gastric emptying studies: Compression of the celiac artery can cause slow or delayed gastric emptying. A gastric emptying study can help your doctor determine how fast your stomach empties its contents.

• #32 MALS (Median Arcuate Ligament Syndrome): Symptoms & Diagnosis

  https://my.clevelandclinic.org/health/diseases/16635-median-arcuate-ligament-syndrome-mals

  Median arcuate ligament syndrome (MALS) refers to a condition that happens when the median arcuate ligament in your chest presses against your celiac artery and nearby nerves (celiac plexus). […] If your healthcare provider thinks you may have MALS, theyll review your medical history and perform a physical exam. […] Your provider may order different blood tests and imaging tests to rule out more common conditions that may cause your symptoms. […] If these tests rule out common conditions, your provider may refer you to a gastroenterologist for more tests, including: Angiogram, Computed tomography (CT) scan, Magnetic resonance imaging (MRI) scan, Mesenteric duplex ultrasound, which checks how blood flows through your celiac artery or if the ligament is pressing on the celiac plexus. […] Your healthcare provider may recommend median arcuate ligament release, which is surgery to remove or release your ligament so its not pressing on your celiac artery. This procedure restores blood flow through your celiac artery and removes pressure on nearby nerves. […] You may hear your symptoms have more to do with your mental health than physical health. For those reasons, you may feel relieved to learn the rare condition median arcuate ligament syndrome is responsible for your symptoms.

• #33 Median arcuate ligament syndrome | Radiology Case | Radiopaedia.org

  https://radiopaedia.org/cases/median-arcuate-ligament-syndrome-3?lang=us

  In median arcuate ligament syndrome (MALS), compression of the celiac axis compromises blood flow and causes symptoms. […] The imaging findings must, therefore, be correlated with the clinical history.

• #34 Mackenzie Hild found relief for her median arcuate ligament syndrome (MALS) at UChicago Medicine – UChicago Medicine

  https://www.uchicagomedicine.org/forefront/heart-and-vascular-articles/mackenzie-hild-found-relief-for-her-median-arcuate-ligament-syndrome

  He warned her, however, „your pain may not go away.” There is not yet a reliable way to predict how a patient, even one who meets all the diagnostic criteria, will respond to the operation. […] „About 70 to 80 percent of our patients have an excellent outcome,” Skelly said, „but we can’t always tell in advance who the lucky ones will be.” […] Skelly sent Hild’s insurance provider her test results, long-term follow-up from previous cases and various publications on MALS diagnosis and treatment. […] The operation, formerly done through a big incision, is now performed laparoscopically, through five small abdominal punctures: two for surgical tools, two for the retractors, and one through the belly button for the biggest item, a high-resolution camera. […] The operation is technically simple, but complicated by the endless variety of individual anatomies. […] They removed the connective and lymphatic tissues above, around and below the celiac artery. […] The next morning, patients are offered clear liquids. […] Over the next few weeks, as her body relearned how to eat, the pain vanished.

• #35 Median Arcuate Ligament Syndrome a dilemma of a delayed diagnosis of a rare disease: A Case Report

  https://www.acquaintpublications.com/article/median_arcuate_ligament_syndrome_a_dilemma_of_a_delayed_diagnosis_of_a_rare_disease_a_case_report76

  Median arcuate ligament syndrome is a rare disorder where there is compression on the celiac trunk by the median arcuate ligament of the diaphragmatic crura. […] Usually, such disease diagnosis is delayed due to difficulty in differentiating signs and symptoms of median arcuate ligament syndrome from other similar presenting diseases such as superior mesenteric artery syndrome, anorexia nervosa, and bulimia. […] Median arcuate ligament syndrome is a rare disease, challenging to diagnose and difficult to differentiate from similar presenting diseases. It requires a high suspicion from the treating physician, and an experienced radiologist to diagnose the findings on required radiological investigations. Early diagnosis cannot be stressed enough to avoid possible dire complications of such disease most importantly, gastroparesis, malnutrition, and kidney injury.

• #36 Median arcuate ligament syndrome: Incidental finding or real problem? | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/88/3/140

  A 43-year-old woman was admitted with pain in the epigastrium and right upper quadrant that radiated to the back and was associated with nausea and dry heaves. […] Computed tomography (CT) of the abdomen revealed compression of the celiac artery by the arcuate ligament. […] CT angiography, magnetic resonance angiography, and duplex abdominal ultrasonography during inspiration and deep expiration are the most common diagnostic studies for MALS. […] MALS is considered a diagnosis of exclusion, and it can coexist with other intra-abdominal pathologies and be a confounding factor. […] To enhance the benefit of surgical intervention, studies aimed at improving the ability to reliably diagnose MALS are required. […] It is generally accepted that asymptomatic or incidentally discovered MALS does not warrant intervention. […] Laparoscopic release of the arcuate ligament has become a widely accepted treatment.

• #37 A Median Arcuate Ligament Syndrome Could Be Re-termed as a Nutcracker Celiac Ganglion Abdominal Pain Syndrome

  https://www.jnmjournal.org/view.html?uid=1832&vmd=Full

  Median arcuate ligament syndrome (MALS) is known as chronic recurrent abdominal pain related to compression of the celiac artery by the median arcuate ligament. […] We suggest renaming MALS as NCGAPS, nutcracker celiac ganglion abdominal pain syndrome, to better explain the mechanism of the recurrent abdominal pain. […] We would like to find the cause and mechanism of pain in patients suffering from abdominal pain without a definite etiology. Therefore, we are proposing a mechanism-based scoring system made out of clinical and radiological characteristics and suggesting a diagnostic process for NCGAPS. […] The 3 patients in the highly suspicious group by NCGAPS scores were asked to perform CTA. However, only 1 patient took the CTA and was confirmed with NCGAPS. […] In conclusion, we suggest renaming the name of MALS as NCGAPS, nutcracker celiac ganglion abdominal pain syndrome, to better explain the mechanism of the recurrent abdominal pain and to raise awareness of the cause of the pain. Only when the etiology of pain is emphasized and the term is easy for patients to understand, gastroenterologists will be alert not to miss the proper diagnosis. Further studies are needed on the diagnostic cutoff of clinical and radiological scores of NCGAPS.

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