Median Arcuate Ligament syndrome

General information about MALS

• MALS is a rare syndrome, seen in only 2 out of 100,000 people.
• It is most often seen in women aged 30-50 years.
• The ratio of women to men is 4:1.
• Scans show that in some populations, 10 to 24% of the population has celiac compression, but a much smaller percentage exhibit symptoms.

(Source: Videnskab)

Differential diagnoses:

There are other diseases and conditions that can mimic MALS symptoms that are more common and are usually ruled out beforehand:

• Disease of the gallbladder or bile ducts
• Hepatitis
• Ulcer
• Appendicitis

MALS – Acute and chronic

Median arcuate ligament syndrome causes intestinal ischemia, which can be divided into two types, acute and chronic. These are diagnosed based on the following criteria: (Source: Sundhed.dk):

Acute:

• Severe, cramping pain in the navel area, accompanied by vomiting and loose stools.
• After 6-12 hours, the entire intestinal system is affected by decreased blood circulation, which can lead to ischemia in the intestines and result in peritoneal retraction.
• It is often accompanied by bloody diarrhea.
• The diagnosis is confirmed by CT scan or laparotomy.

Chronic:

• Often a longer medical history with pain that occurs ½ hour after a meal.
• Changed bowel movements, either loose stools or sudden constipation.
• This is often discovered in connection with other examinations and scans of the abdomen to rule out other diseases that can cause weight loss.

Symptoms of medial arcuate ligament syndrome (MALS)

Abdominal pain: Persistent and intense pain in the upper abdomen is a characteristic symptom. The pain may worsen after meals, especially larger meals.

Weight loss: Unexplained weight loss may be a result of decreased appetite due to pain when eating.

Nausea and vomiting: MALS patients may experience periodic nausea and vomiting, especially after meals.

Food intolerance: Some patients develop intolerance to certain foods as the pain after consuming them can create a negative association with food.

Pain radiating to the back: The pain from MALS can radiate to the back and worsen with certain movements or positions.

Increased pain during physical activity: Some patients may experience increased pain during or after physical activity.

Worsening of symptoms over time: Symptoms may develop gradually and worsen over time.

(Source: National Library of Medicine)

Causes of MALS

Science has not yet found a clear explanation for why celiac artery compression syndrome occurs. The uncertainty arises because the anatomical compression of the celiac artery by the median arcuate ligament can also be seen in patients without symptoms. In other words, not all patients with this anatomical compression develop symptoms.

The median arcuate ligament is a fibrous band that connects the two medial borders of the diaphragmatic crus, usually near the 12th thoracic or first lumbar vertebra. Compression of the celiac artery can occur in two anatomical situations: an abnormal cranial origin of the celiac artery or an abnormal caudal attachment of the diaphragm. Congenital factors can affect the level of diaphragm attachment or the origin of the celiac artery. (Source: National Organization for Rare Disorders)

Is MALS dangerous?

MALS is NOT dangerous, but it can cause severe pain or discomfort. As described earlier, this pain is often localized in the abdominal region, especially in connection with a meal. If you have MALS, it is recommended to seek treatment.

Prognosis for Median Arcuate Ligament Syndrome

After surgery, 60-70% experience relief of symptoms. In some cases, this is an immediate effect, while in other cases it can take up to a few months before there is an effect.

Treatment for MALS

Since the symptoms and cause are related to compression of the celiac artery, it is recommended to receive treatment to relieve this pressure. There are currently no known conventional treatments that can alleviate this.

The most effective treatments have been surgical procedures that relieve pressure from the ligament and thus improve the conditions of the celiac artery.

However, there is an effect of surgery on the ligament, which is performed in one of two ways: traditional open surgery or minimally invasive method (laparoscopy).

Osteopathic approach to MALS

As osteopaths, we work with a holistic view of the body, where we map the body’s resources and deficiencies, and through manual techniques, advice and guidance, we try to optimize these conditions. We do this by assessing the immune system, nervous system, organ system, hormonal system, circulatory system and musculoskeletal system.

Osteopathic examination and treatment of the Median arcuate ligament will depend on several factors that can influence the diaphragm and thereby also influence the ligament:

Biomechanically; if there is immobility in the back and/or rib cage which can lead to compensation at the thoracolumbar junction which causes tension in the diaphragm, this can lead to a worsening of symptoms.

The immune system; if you have been sick recently and have either had a cough or other type of symptom that can cause strain on the lungs or nearby organs, this can cause an increased tone in the diaphragm.

The circulation; since MALS has an effect on the circulation in the abdomen, an osteopath will be able to work on optimizing conditions in the immediate area, to increase blood circulation and possibly be able to work with tension in the diaphragm.