Median arcuate ligament syndrome: An unusual cause of chronic abdominal pain

A 58-year-old woman with a body mass index of 25.9 kg/m² intermittently suffered from postprandial epigastric pain for nearly five years, which continued to be aggravated for more than 10 min, accompanied by acid regurgitation but no nausea, vomiting, diarrhea, weight loss, or other discomfort. A painless, prehospital gastroscopy was conducted, which suggested chronic atrophic gastritis, and the 13C-urea breath test was positive. The patient was then treated with proton pump inhibitors (PPI), anti-spasmodics, and antibiotics. The gastroscopy was reconducted and showed an improvement of the gastritis, but the symptoms of abdominal pain were not completely improved. It appeared that chronic gastritis could not explain the symptoms of postprandial epigastric pain. After admission, abdominal physical examination did not reveal any findings. A painless gastroscopy showed that the patient had chronic atrophic gastritis, and no abnormalities could be seen by enteroscopy. Abdominal ultrasound revealed hepatic cysts but no biliary, pancreatic, or renal lesions. Enhanced computed tomography (CT) of the abdominal pelvis showed stenosis of the celiac artery without atherosclerosis, pointing to median arcuate ligament syndrome (MALS) (Fig. A). A sagittal view of the CT angiography showed compression of the celiac artery (Fig. B). The patient was classified as Type A MALS according to stenosis rate < 50% and length of stenosis ≤ 3 mm, which should be followed up regularly without operation. The patient refused any surgical treatment. After 3 months of follow-up, the patient returned and noted that she still felt post-meal pain as before, but there was no change in body weight.