Uncommon Ethiology in Abdominal Pain: Celiac Axis Compression Syndrome

Celiac axis compression syndrome, one of the reasons of mesenteric ischemia, is an extremely rare etiology of abdominal pain. Primary pathological mechanism is the external compression of the celiac trunk by median arcuate ligament. The diagnosis of this condition is usually difficult and depends on angiographic findings and computerized tomography (CT) evaluations. Here we report a celiac axis compression syndrome case, presenting with chronic abdominal pain and weight loss, which was successfully treated by surgery.

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

The 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.Patients can often be misdiagnosed for several years before a correct diagnosis is established,also due to a medical team’s clinical suspicion.We present a case series of two patients who suffered from MALS and were treated successfully.The first patient is a 32-year-old woman,presenting with post-prandial abdominal pain and weight loss that have lasted for the past ten years.The second patient,a 50-year-old woman,presented with similar symptomatology,with the symptoms lasting for the last five years.Both cases were treated by laparoscopic division of the median arcuate ligament fibers,which alleviated extrinsic pressure from the celiac artery.Previous cases of MALS were retrieved from PubMed,to assemble a better diagnostic algorithm and propose a treatment method of choice.The literature review suggests an angiography with a respiratory variation protocol as the diagnostic modality of choice,along with the laparoscopic division of the median arcuate ligament fibers as the proposed treatment of choice.

Median arcuate ligament syndrome complicated with gallbladder stones:A case report

BACKGROUND Median arcuate ligament syndrome(MALS)is a rare disease caused by compression of the celiac trunk artery by the median arcuate ligament(MAL).It can cause symptoms of postprandial abdominal pain,weight loss,and nausea and vomiting.CASE SUMMARY A 55-year-old woman was admitted due to abdominal pain,nausea and vomiting.On admission,the patient presented with epigastric pain that worsened after eating,without signs of peritoneal irritation.Computed tomography angiography of the upper abdomen showed compression of the proximal segment of the abdominal trunk,local luminal stenosis with angular“fishhook”changes,which changed significantly during forceful inspiration and expiration;gallbladder stones;and multiple cysts in the liver.Abdominal duplex ultrasonography showed that peak systolic velocity was 352 cm/s.After diagnosis of MALS was confirmed,an arch ligament release procedure was performed.MALS has no specific symptoms and can be misdiagnosed as other abdominal diseases.Awareness of MALS should be improved to avoid misdiagnosis.The commonly used treatment option is MAL release and resection of the peripheral ganglion of the celiac trunk artery.CONCLUSION The diagnosis and treatment of MALS must be individualized,and MAL release is effective and provides immediate symptomatic relief.

Diagnosis and management of splanchnic ischemia

Splanchnic or gastrointestinal ischemia is rare and randomized studies are absent. This review focuses on new developments in clinical presentation, diagnostic approaches, and treatments. Splanchnic ischemia can be caused by occlusions of arteries or veins and by physiological vasoconstriction during low-flow states. The prevalence of significant splanchnic arterial stenoses is high, but it remains mostly asymptomatic due to abundant collateral circulation. This is known as chronic splanchnic disease (CSD). Chronic splanchnic syndrome (CSS) occurs when ischemic symptoms develop. Ischemic symptoms are characterized by postprandial pain, fear of eating and weight loss. CSS is diagnosed by a test for actual ischemia. Recently, gastro-intestinal tonometry has been validated as a diagnostic test to detect splanchnic ischemia and to guide treatment. In single- vessel CSD, the complication rate is very low, but some patients have ischemic complaints, and can be treated successfully. In multi-vessel stenoses, the complication rate is considerable, while most have CSS and treatment should be strongly considered. CT and MR-based angiographic reconstruction techniques have emerged as alternatives for digital subtraction angiography for imaging of splanchnic vessels. Duplex ultrasound is still the first choice for screening purposes. The strengths and weaknesses of each modality will be discussed. CSS may be treated by minimally invasive endoscopic treatment of the celiac axis compression syndrome, endovascular antegrade stenting, or laparotomy-assisted retrograde endovascular recanalization and stenting.The treatment plan is highly individualized and is mainly based on precise vessel anatomy, body weight, co- morbidity and severity of ischemia.

Median arcuate ligamentum syndrome:Four case reports

BACKGROUND Median arcuate ligamentum syndrome(MALS)is a disease entity with unclear pathogenesis.If it is not considered in advance,the clinical diagnosis of the disease is very difficult because patients complain of digestive discomfort including pain.However,this characteristic is not specific to MALS.There have been no studies to assist in making a quick diagnosis.The aim of this case series was to recognize that MALS must be considered as a differential factor in the cause of abdominal pain.CASE SUMMARY We described cases in which four patients complained of abdominal pain over a long period but in whom a diagnosis of MALS could not be made.If the gastroenterologist does not take into account abdominal pain in advance,the patient is considered an asymptomatic gallstone patient and has their gallbladder removed despite imaging evaluation.The patient may also be considered a psychiatric patient and may be administered psychiatric drugs over a long period.In all four cases in this report,the patients experienced abdominal pain.In three cases,the diagnosis was possible by the clinician’s judgment considering both clinical symptoms and imaging techniques shortly after the onset of symptoms.However,in one case that lasted over 20 years,a clear diagnosis was not possible.Even after complaining of colicky pain and performing a cholecystectomy,the diagnosis was made only after the symptoms persisted.In all four cases,the symptoms were relieved by neuromodulators.CONCLUSION MALS is a rare disease and it is easy to miss because it is not malignant,but patients can suffer from pain over a long period.For the accurate diagnosis of a patient complaining of abdominal pain,the diagnosis must be differentiated.In addition,as there are asymptomatic patients,patients who need treatment should be carefully selected,and improvement with medical treatment can be expected.Large-scale studies are also needed.