S6380 Starved by Anatomy: The Overlooked Culprit Behind Chronic Epigastric Pain

Introduction: Median arcuate ligament syndrome (MALS), also known as celiac artery compression syndrome, is a rare vascular disorder caused by external compression of the celiac artery by the median arcuate ligament of the diaphragm. It predominantly affects middle-aged women with slender body habitus and is frequently underdiagnosed due to its nonspecific gastrointestinal symptoms. Case Description/Methods: We report the case of a 45-year-old man with a history of rheumatoid arthritis who presented with a 5-week history of progressive, severe epigastric pain and a 30-pound unintentional weight loss. Initial investigations including upper endoscopy and laboratory studies were unrevealing. Computed tomography (CT) angiography demonstrated significant celiac artery stenosis with characteristic features of MALS, confirmed by Doppler ultrasonography showing elevated expiratory-phase velocities. Given the patient’s symptom burden and imaging findings, he underwent successful median arcuate ligament release surgery, resulting in marked clinical improvement. MALS remains a diagnosis of exclusion, typically confirmed through a combination of imaging modalities. Its pathophysiology may involve both ischemic and neuropathic mechanisms. Surgical decompression with celiac ganglionectomy remains the definitive treatment and is associated with favorable outcomes when performed in appropriately selected patients. Discussion: This case highlights the importance of maintaining a high index of suspicion for MALS in patients presenting with chronic, unexplained abdominal pain and significant weight loss. Early diagnosis and prompt surgical management can lead to significant symptom resolution and improved quality of life.