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 that affects approximately 2 per 100,000 people. […] The prevalence of MALS is uncertain, primarily because its clinical manifestations can vary significantly, with many asymptomatic cases only being discovered after patients undergo imaging with a CT scan. That said, it is estimated that 13% to 50% of the population has some degree of compression of the celiac artery by the MAL. […] Other risk factors for MALS include smoking, hypertension, hyperlipidemia, malnutrition, and prior abdominal surgeries. […] Mental disorders such as anxiety disorders, depression, panic disorder, and post-traumatic stress disorder are common comorbidities that present alongside MALS in many cases. […] 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.

• #2 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. MALS is a rare and is more common in females having thin body habitus in the 3rd to 5th decade of life. The syndrome consists of postprandial symptoms including pain, nausea, vomiting, diarrhea and unexplained weight loss. MALS is usually a diagnosis of exclusion. The treatment of MALS aims at decompression of celiac artery to establish adequate blood flow and pain management by neurolysis. The role of intervention radiology is emerging in the treatment of MALS, though its outcomes are not promising. The present trend is laparoscopic release of arcuate ligament with intraoperative duplex ultrasound. There is role of PTA in post-surgical recurrence. MALS is a rare entity and a diagnosis of exclusion. The diagnosis is difficult and needs a high grade of suspicion with supportive imaging findings.

• #3

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

  Median arcuate ligament syndrome (MALS) is a rare clinical condition in which the celiac trunk is compressed by the median arcuate ligament during expiration. MALS often presents as a triad of symptoms: postprandial abdominal pain, bowel function disorder, and weight loss. It is more likely to affect young, thin adult females (F:M ratio of 4:1). The range of patients with celiac compression has been reported between 10% and 24%. However, the overall incidence of symptomatic celiac artery compression syndrome is about 2 per 100,00 patients. […] 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. At this time, there is not a consensus to workup; however, mesenteric duplex ultrasound, angiography, and gastric exercise tonometry are all available options. 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.

• #4 Atypical Presentation of Median Arcuate Ligament Syndrome in the Emergency Department – The Western Journal of Emergency Medicine

  https://westjem.com/case-report/atypical-presentation-of-median-arcuate-ligament-syndrome-in-the-emergency-department.html

  Celiac artery compression syndrome, also called median arcuate ligament syndrome (MALS), is a rare condition in which the diaphragmatic crura compresses the celiac axis. This results in a constellation of primarily gastrointestinal (GI) symptoms including nausea, vomiting, postprandial abdominal pain, and weight loss. […] The incidence of MALS is estimated at approximately two per every 100,000 patients. […] The majority of MALS patients are relatively young women between the ages of 20-50 years old with thin body habitus who have been extensively worked up for various intra-abdominal pathology. […] While a significant portion of the United States population may have some underlying compression of the celiac axis, a much smaller percentage of these individuals may develop symptoms of MALS. […] The above case brings awareness of this uncommon disease to ED professionals, and demonstrates that it may occur in patients who do not fit its typical epidemiological demographics.

• #5 Median arcuate ligament syndrome – Wikipedia

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

  Median arcuate ligament syndrome is a rare condition characterized by abdominal pain attributed to compression of the celiac artery and the celiac ganglia by the median arcuate ligament. […] It is estimated that in 10-24% of normal, asymptomatic individuals the median arcuate ligament crosses in front of (anterior to) the celiac artery, causing some degree of compression. Approximately 1% of these individuals exhibit severe compression associated with symptoms of MALS. The syndrome most commonly affects individuals between 20 and 40 years old, and is more common in women, particularly thin women.

• #6 Median arcuate ligament syndrome | HKMJ

  https://www.hkmj.org/abstracts/v22n2/184.e3.htm

  Median arcuate ligament syndrome was first described in 1963 by Harjola and in 1965 by Dunbar et al. The definition of the syndrome relies on a combination of both clinical and radiographic features. Extrinsic compression of the celiac trunk by the MAL occurs in 10% to 24% of patients. The disease typically occurs in young patients and is more common in thin women who may present with epigastric pain and weight loss. The diagnosis of celiac artery compression is traditionally made following conventional angiography. The majority of affected patients have no symptoms, thus radiographic finding of celiac axis compression alone may not be significant, unless it is correlated with clinical symptoms. Severe compression occurs in approximately 1% of patients. The surgical management of MAL syndrome is controversial. Surgical treatment in severe cases is advocated, particularly in cases with post-stenotic dilatation and collateral vessels, by division of the ligament.

• #6 Median arcuate ligament syndrome | HKMJ

  https://www.hkmj.org/abstracts/v22n2/184.e3.htm

  The use of thin-section multidetector CT and three-dimensional imaging techniques has greatly improved the ability to non-invasively obtain detailed images of the mesenteric vessels. Computed tomographic angiography can play a role in the diagnosis of this condition by demonstrating the characteristic focal narrowing of the celiac artery with a hooked appearance that distinguishes this condition from other causes of celiac artery narrowing, such as atherosclerotic disease.

• #7 Clinically Significant Progression of Median Arcuate Ligament Syndrome – Madigan | Wake Forest University School of Medicine

  https://school.wakehealth.edu/about-the-school/wake-forest-journal-of-science-and-medicine/summer-2021/clinically-significant-progression-of-median-arcuate-ligament-syndrome

  Median arcuate ligament syndrome (MALS) is a poorly understood condition characterized by compression of the celiac artery by a fibrous ligament connecting the diaphragmatic crura. […] Severe stenosis of the celiac artery is predicted to affect 1% of patients with imaging findings of MALS. […] Recognition of MALS as a potential etiology in the diagnostic evaluation of abdominal pain is of growing clinical importance. Increased bariatric surgery incidence leads to a higher prevalence of patients with rapid weight loss: a major risk factor for the development of MALS. […] Epidemiologic review of cases revealed higher incidence in females (4:1), notably between the ages of 40 and 60 years old.

• #8 Median arcuate ligament syndrome often poses a diagnostic challenge: A literature review with a scope of our own experience

  https://www.wjgnet.com/1948-9366/full/v15/i6/1048.htm

  Based on this percentage, MALS could be responsible for more cases of chronic mesenteric ischemia than previously thought. […] The diagnostic modalities that are more commonly used include CT of the abdomen with IV contrast, magnetic resonance angiography (MRA), or Doppler ultrasound with a respiratory variation protocol. […] A study by Skeik et al stated that the prevalence for MALS among other non-atherosclerotic abdominal arterial vasculopathies was found to be around 15.3%. […] To prevent the mentioned complications and operative risks, a definitive diagnosis should be established in patients presenting with chronic mesenteric ischemic symptoms. […] Because these symptoms are non-specific, an extensive workup must be ordered, including right upper quadrant ultrasonography, abdominal CT, and upper endoscopy.

• #9 Median arcuate ligament syndrome (MALS) – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/median-arcuate-ligament-syndrome-mals/symptoms-causes/syc-20505001

  Median arcuate ligament syndrome is more common in adults than in children. […] It also is more common among women than among men. […] Median arcuate ligament syndrome (MALS) can occur in anyone, even children. […] MALS has been seen in identical twins, so genetics may play a role. […] The exact cause of median arcuate ligament syndrome, also called MALS, is not known. […] Because the cause of MALS is poorly understood, the risk factors are unclear. […] A complication of median arcuate ligament syndrome, also called MALS, is long-term pain, especially after meals. […] MALS symptoms may be vague. […] It may take some time to get an accurate diagnosis.

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

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

  Median arcuate ligament syndrome is more common in adults than in children. […] It also is more common among women than among men. […] 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. […] The exact cause of median arcuate ligament syndrome, also called MALS, is not known. […] Because the cause of MALS is poorly understood, the risk factors are unclear. […] MALS also has been seen in identical twins, so genetics may play a role. […] Some people have developed median arcuate ligament syndrome after pancreatic surgery or blunt injury to the upper stomach area. […] A complication of median arcuate ligament syndrome, also called MALS, is long-term pain, especially after meals.

• #11 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 may affect both men and women of all ages but most often seems to affect young females between the ages of 30 to 50. It is approximately four times more likely to occur in women than in men. […] Diagnosing MALS can be difficult since the symptoms overlap with that of many, many other conditions including GERD, gastroparesis, liver conditions, or gallbladder problems. […] 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. […] Studies show that approximately 60% to 80% of patients who underwent celiac artery decompression experienced relief of their symptoms following surgery. […] MALS does not resolve on its own, but it can be treated with surgery. Surgical treatment effectively reduces or eliminates symptoms in 60% to 80% of people.

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

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

  Women with MALS outnumber men by 2:1 to 3:1, and the typical age of onset is in the fourth and fifth decades. […] MALS is considered a diagnosis of exclusion, and it can coexist with other intra-abdominal pathologies and be a confounding factor. […] The increasing use of CT in the assessment of abdominal pain has led to more frequent diagnosis of MALS. […] In a retrospective study, Heo et al showed that 87% of patients with MALS had no symptoms, and the condition was incidentally diagnosed by CT. […] Anatomically, up to 24% of the population may have compression of the celiac artery; however, fewer than 1% of them have symptoms. […] It is generally accepted that asymptomatic or incidentally discovered MALS does not warrant intervention.

• #13 Prevalence and Characteristics of Patients with Median Arcuate Ligament Syndrome in a Cohort Diagnosed with Celiac Artery Compression – PubMed

  https://pubmed.ncbi.nlm.nih.gov/36476640/

  Median arcuate ligament syndrome (MALS) is a frequent differential diagnosis in patients with postprandial abdominal symptoms, but diagnosis remains challenging. […] The aim of this study was to identify characteristics of patients who had MALS compared with non-MALS patients among a cohort of patients diagnosed with celiac artery compression (CAC). […] Two hundred ninety-three patients with a diagnosis of CAC were identified; 59.7% were women, and average age was 63.9 20.2 years. […] Sixty-nine (23.5%) patients with CAC had MALS. […] There were no significant differences in sex or race between MALS and non-MALS patients, but MALS patients were younger (55.7 vs 68.1, p 0.001). […] Patients with MALS were less likely to have diabetes (12.5% vs 26.9%), renal disease (4.6% vs 8.2%), hypertension (41.5% vs 70.3%), mesenteric atherosclerotic disease (14% vs 61.9%), and peripheral artery disease (15.0% vs 39.7%). […] We demonstrate a novel observation that MALS patients tend to have fewer atherosclerotic characteristics than non-MALS patients with CAC. […] An important clinically relevant feature of MALS patients may be their lack of atherosclerotic phenotype compared with non- MALS patients with CAC.

• #14 Median arcuate ligament syndrome (MALS) – Vejthani Hospital | JCI Accredited International Hospital in Bangkok, Thailand.

  https://www.vejthani.com/diseases-conditions/median-arcuate-ligament-syndrome-mals/

  Median arcuate ligament syndrome (MALS) develops when the artery that supplies blood to the upper abdomen is compressed by the arc-shaped band of tissue in the chest region. MALS can strike anyone, including children. The MALS is also known as celiac axis syndrome, Dunbar syndrome, or celiac artery compression. […] The risk factors for MALS are uncertain because it is unclear what causes the illness. MALS has been observed in children, including twins, suggesting that genetics may be involved.

• #15 Psychiatric comorbidities of median arcuate ligament syndrome: Indications for intervention across the lifespan

  https://www.probiologists.com/article/psychiatric-comorbidities-of-median-arcuate-ligament-syndrome-indications-for-intervention-across-the-lifespan

  Median Arcuate Ligament Syndrome (MALS) is the terminology that describes the vascular compression of the celiac artery, which at times is associated with numerous gastrointestinal symptoms. Most notably, patients with MALS present with epigastric pain, often worsening post-prandially, and weight loss. […] The diagnosis of MALS is further complicated by the high incidence of psychopathology noted in this disease population. […] Given the association of poorer clinical outcomes for adults and pediatric patients with MALS with psychiatric symptoms and disorders, evaluation and implementation of treatment for such disorders prior to surgery is crucial.

• #16 Laparoscopic surgery for median arcuate ligament syndrome | VHRM

  https://www.dovepress.com/laparoscopic-surgery-for-median-arcuate-ligament-syndrome-mals-a-prosp-peer-reviewed-fulltext-article-VHRM

  MALS is a disorder known to be due to external compression of the CA by the fibrotic preaortic celiac ganglionic tissue and the median arcuate ligament. The incidence of MALS has been estimated to be about 12/100,000 patient years. […] The typical symptoms were postprandial abdominal pain, changes in eating patterns, and weight loss in fifty-one patients (98%). […] This study demonstrates symptom relief achieved in 90% of patients with MALS operated with laparoscopic decompression. The symptom relief was either complete (67%) or partial (23%) within 36 months after laparoscopic decompression of the CA. […] Laparoscopic decompression of the celiac artery seems to provide persistent relief from symptoms in most patients with median arcuate ligament syndrome.

• #17 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

  The MALS is most commonly seen in young and female patients aged between 20 and 40 years. The syndrome is characterized by typical postprandial signs including epigastric pain, weight loss, and nausea. The abdominal pain usually starts within the 15 – 30th minutes after eating. In the cases with MALS, the celiac artery is narrowed by the MAL during expiration. […] 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.

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

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

  Median Arcuate Ligament Syndrome (MALS) also known as Dunbar’s syndrome is one of the main factors leading to Celiac Artery Stenosis (CAS). This very rare syndrome affecting 0.002% of the population, and its diagnostic and surgical management are not well defined. The characteristic presentation of a patient with MALS is that of a young female, without comorbidities of atherosclerotic phenotype. MALS may remain asymptomatic in up to 25% of affected patients, while, according to different article, between 15% and 50% of asymptomatic cases can still be identified. The most common associated symptoms include postprandial abdominal pain, nausea and vomiting, weight loss, bloating, abdominal bruit and increased epigastric tenderness. The aim of this review is to discuss the clinical and imaging features, therapeutic management and potential future research directions that may be useful in the early diagnosis and treatment of MALS from a vascular surgeon’s perspective. In addition, the review emphasizes, the need for a multidisciplinary approach involving the vascular surgeon, radiologist, gastroenterologist and psychologist to optimally manage patients with MALS. MALS symptoms such as postprandial epigastric pain or nausea are non-specific and therefore this diagnosis should be considered only after excluding other, more common diseases. European guidelines on management of chronic mesenteric ischemia (CMI) recommend use of contrast-enhanced magnetic resonance angiography (CE-MRA), computed tomography angiography (CTA) or expiratory/inspiratory duplex ultrasound (DUS) in the diagnosis of celiac trunk compression. 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. The use of standardized diagnostic protocol could improve patient outcomes. Studies confirm that MALS can coexist with other conditions involving arterial compression. Various diagnostic and therapeutic strategies have been discussed in the previous sections. Importantly, MALS is currently the subject of two clinical trials.

• #19 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. […] The prevalence of MALS remains unclear, which is partly due to its variable clinical presentation. […] MALS occurs most commonly in young women. […] MALS is a diagnosis of exclusion and is typically the result of extensive investigations to exclude more common, alternative causes of abdominal pain. […] 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.

• #19 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

  Those with MALS who have appropriate work-up, diagnosis and management have been found to have good outcomes in case series. Further consensus on diagnostic criteria and management is required. […] An increased awareness of MALS would permit earlier consideration and investigation of the syndrome as part of a diagnostic work-up for patients with symptoms of abdominal pain and weight loss not attributable to more common conditions.

• #20 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 rare condition, with a couple of thousand cases treated annually in the U.S. The condition most often occurs in thin, younger women. […] 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. […] Most people who have surgery for MALS will have a duplex ultrasound a month after their procedure to check to see that there is no further compression of the median arcuate ligament.

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

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

  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. […] 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.

• #22 Median Arcuate Ligament Syndrome | Applied Radiology

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

  Median arcuate ligament syndrome (MALS), also known as Dunbar Syndrome, is an uncommon condition where the MAL compresses the celiac trunk. […] MALS typically affects women 20-40 years of age, most commonly at a ratio of 2:1 or 3:1 that of the general population. The incidence of MALS is approximately 2 per 100,000. […] Other common etiologies such as GERD, gastritis, and Crohn disease must first be excluded before MALS can be diagnosed. […] A peak systolic velocity of 200cm/s within the artery during expiration has a sensitivity of 75% and a specificity of 89% for MALS. […] 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. Laparoscopic surgery is typically the therapeutic option.

• #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. […] MALS is often considered a diagnosis of exclusion, which is determined after other gastrointestinal disorders have been ruled out, and is strongly supported by the presence of severe epigastric pain with concomitant compression or narrowing of the celiac artery. […] Patients with MALS often undergo a multidisciplinary evaluation with several specialties including gastroenterology, vascular surgery, general surgery, cardiology, anesthesia pain management, interventional radiology, and psychological assessment.

• #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. […] 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. […] A recent landmark study presented by Gustavo Oderich, MD and colleagues summarized the long-term follow up of 100 consecutive patients treated for MALS.

• #24

  https://link.springer.com/article/10.1007/s00464-022-09431-3

  Median arcuate ligament syndrome is a rare disease with overlapping symptoms of broad foregut pathology. […] Overall numbers of surgical intervention for treatment of median arcuate ligament increased during this timeframe, as well as increased utilization of the laparoscopic approach. […] It appears to be an overall safe procedure, offering lower rates of complications and shorter length of stay.

• #25 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

  Several studies on MALS have been conducted, but the previous studies had focused on imaging tools and did not deal with the clinical implications in detail. […] We thought that the characteristics of the pain in these patients are important and the mechanism of the pain is eventually the compression of the celiac trunk ganglion by medical arcuate ligament based on our case series. […] Thus, we would like to suggest MALS as nutcracker celiac ganglion abdominal pain syndrome (NCGAPS) so that the patients and physicians can easily understand the cause of pain. […] We suggest renaming MALS as NCGAPS, nutcracker celiac ganglion abdominal pain syndrome, to better explain the mechanism of the recurrent abdominal pain. […] Further studies on the diagnostic cutoff of clinical and radiological scores of NCGAPS are needed not to miss the diagnosis of NCGAPS.

• #26 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

  In this study we suggest a new clinical term, NCGAPS, instead of MALS and a novel diagnostic algorithm. […] NCGAPS is overlooked as a cause of abdominal pain because it is still considered a very rare disease and the mechanism is unclear. […] Our study suggests a diagnostic process of abdominal pain of unknown etiology. […] 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.

• #27

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

  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.

• #28 Median arcuate ligament syndrome often poses a diagnostic challenge: A literature review with a scope of our own experience

  https://www.wjgnet.com/1948-9366/full/v15/i6/1048.htm

  Median arcuate ligament syndrome (MALS) is recognized as a rare clinical entity, characterized by chronic post-prandial abdominal pain, nausea, vomiting, and unintentional weight loss. […] Due to its vague symptomatology, it is mainly regarded as a diagnosis of exclusion. […] The European Society for Vascular Surgery guidelines regarding diseases of the mesenteric arteries and veins state that MALS is the most common cause of single vessel abdominal arterial stenosis. […] Due to the confusing overlapping symptomatology between MALS and other chronic mesenteric ischemic clinical entities, many researchers believe that the syndrome may be under-diagnosed, as is the case in many patients with chronic mesenteric ischemia due to diagnostic delay. […] Most clinical guidelines come from the systematic review and meta-analyses based on individual case reports and case series.

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