Abstract Background Median Arcuate Ligament Syndrome (MALS), also termed celiac artery compression syndrome, is an uncommon cause of chronic abdominal pain resulting from extrinsic compression of the proximal celiac trunk by the median arcuate ligament, often with associated celiac plexus irritation. Symptoms classically include post-prandial epigastric pain with nausea and/or weight loss, and the diagnosis is frequently one of exclusion after more common gastrointestinal causes are ruled out. While radiographic celiac axis compression may be seen incidentally, clinically significant symptomatic MALS is rare. It most commonly affects young to middle-aged females. Recommended evaluation begins with exclusion of alternative gastrointestinal pathology (for example, endoscopy and cross-sectional abdominal imaging). Vascular assessment is then performed using dynamic studies such as duplex ultrasound demonstrating respiratory variation, complemented by CTA or MRA showing focal proximal celiac artery narrowing with characteristic morphology. These modalities help confirm hemodynamically significant stenosis and correlate imaging with symptoms. The standard treatment for symptomatic MALS is surgical decompression by division of the median arcuate ligament (open, laparoscopic, or robotic), with or without celiac plexus neurolysis. Adjunctive endovascular intervention or arterial reconstruction may be considered in selected cases with persistent residual stenosis after adequate release. Case presentation We report a 36-year-old athletic, non-smoking female presenting with recurrent post-prandial abdominal pain. Her surgical history was notable for laparoscopic sleeve gastrectomy performed four years before presentation. Comprehensive evaluation including CT abdomen, upper GI endoscopy, MRA, and Doppler ultrasound demonstrated median arcuate ligament compression of the celiac trunk with luminal narrowing. She underwent laparoscopic median arcuate ligament release with successful decompression. At follow-up, she reported marked symptomatic improvement and remained clinically well. Conclusion This case highlights MALS as an important differential diagnosis in post-bariatric patients with persistent post-prandial pain after negative standard gastrointestinal workup. Prior sleeve gastrectomy can bias evaluation toward more common postoperative aetiologies; however, vascular compression should be considered to avoid delayed diagnosis and to enable definitive minimally invasive treatment.
Fadhel Alzahrani (Thu,) studied this question.