What is celiac artery compression syndrome and how does it occur?
Celiac artery compression syndrome occurs when an arc-shaped band of tissue in the chest area (median arcuate ligament) presses on the artery that sends blood to the upper abdomen.
This artery is called the celiac artery and MALS can cause stomach pain in some people. The median arcuate ligament, which sits above the artery, typically runs along the aorta, the largest blood vessel in the body. However, this ligament or artery can become dislodged and this can cause MALS. The ligament can also put pressure on the nerve network surrounding the celiac artery.
Celiac Artery Branches (Truncus Coeliacus Branches)
The celiac artery (truncus coeliacus) is an important vessel in the abdomen that carries blood to vital organs. The celiac artery divides into three main branches: the left gastric artery (arteria gastrica sinistra), the splenic artery (arteria splenica) and the common hepatic artery (arteria hepatica communis). These arteries supply the foregut, foregut derivatives and the spleen.
Left Gastric Artery (Arteria Gastrica Sinistra)
The left gastric artery gives off branches that supply the lower part of the oesophagus (oesophagus). The vessel then travels along the smaller gastric curvature (curvatura minor) and anastomoses with the right gastric artery (arteria gastrica dextra). This anastomosis is an important collateral circulation route.
Splenic Artery (Arteria Splenica)
The splenic artery runs behind the stomach (retrogastric) and gives rise to the left gastroepiploic artery (arteria gastroepiploica sinistra), which carries blood to the proximal greater gastric curvature (curvatura major). The splenic artery also gives branches to the tail and body of the pancreas. The short gastric arteries (arteriae gastricae breves) supplying the gastric fundus (fundus gastricus) also branch from the splenic artery. These blood vessels do not anastomose with other arteries. Occlusion or rupture of the splenic artery can cause ischaemia of the gastric fundus, which has no collateral blood supply.
Common Hepatic Artery (Arteria Hepatica Communis)
The common hepatic artery is the only arterial supply of the liver (hepar). This blood vessel gives off the proper hepatic artery (arteria hepatica propria), the gastroduodenal artery (arteria gastroduodenalis) and the right gastric artery.
The proper hepatic artery forms the right (arteria hepatica dextra) and left hepatic arteries (arteria hepatica sinistra). The right gastric artery supplies blood to the pylorus and the distal part of the small curvature of the stomach.
The right and left hepatic arteries supply blood to the respective liver lobes. The cystic artery (arteria cystica), usually a branch of the right hepatic artery, supplies blood to the gallbladder (vesica fellea). This blood vessel originates from the left gastric artery in about 1.2% of cases.
The gastroduodenal artery gives off the right gastroepiploic artery (arteria gastroepiploica dextra) and the superior pancreaticoduodenal arteries (arteria pancreaticoduodenalis superior).
The right gastroepiploic artery supplies the distal part of the greater curvature of the stomach. The superior pancreaticoduodenal artery supplies blood to the proximal head of the pancreas and part of the duodenum (duodenum).
The head of the pancreas is the most common site of pancreatic adenocarcinoma (pancreatic cancer) and is usually removed in a Whipple procedure.
Celiac Artery Branches and the Regions They Feed
Artery | Feeding Region |
Left Gastric Artery (Arteria Gastrica Sinistra) | Lower part of the oesophagus, small stomach curvature |
Splenic Artery (Arteria Splenica) | Large stomach curvature, tail and body of the pancreas, stomach fundus |
Common Hepatic Artery (Arteria Hepatica Communis) | Liver, pylorus, duodenum, gall bladder |
Proper Hepatic Artery (Arteria Hepatica Propria) | Right and left liver lobes |
Right Gastric Artery (Arteria Gastrica Dextra) | Pylorus, distal part of the small stomach curvature |
Cystic Artery (Arteria Cystica) | Gall bladder |
Gastroduodenal Artery (Arteria Gastroduodenalis) | Large curvature distal part of the stomach, pancreatic head, duodenum |
Superior Pancreaticoduodenal Artery (Arteria Pancreaticoduodenalis Superior) | Pancreatic head, duodenum |
The branches of the celiac artery and the areas they supply are critical for the healthy functioning of the intra-abdominal organs. Each branch supplies specific organs and regions, and any blockage or injury can lead to serious health problems. The anastomoses between these arteries ensure the continuity of blood flow by providing collateral circulation.
What is MALS (Median Arcuate Ligament Syndrome)?
MALS occurs when the position of the median arcuate ligament and celiac artery varies from person to person.This condition is also called median arcuate ligament syndrome or celiac artery compression syndrome. It is also known as MALS, celiac artery compression, celiac axis syndrome or Dunbar syndrome.
MALS (Median Arcuate Ligament Syndrome) Symptoms and Diagnosis:
Celiac artery compression syndrome is usually associated with compression of the celiac artery and the symptoms can be varied. Chronic stomach pain is the most common symptom of MALS.
Other symptoms include increased stomach pain after meals or exercise, bloating, diarrhoea, weight loss and nausea/vomiting. These symptoms may be caused by reduced blood flow in the celiac artery or compression of nerves in the area.
Symptoms of Celiac Artery Compression (Stenosis) Syndrome:
Epigastric pain or pressure
Pain or pressure after eating
Chest pain or pressure
Nausea
Diarrhoea or constipation
Dizziness or lightheadedness
Bloating
Vomiting
Significant weight loss
Radiating right or left flank and/or back pain
Blood pressure and pulse problems
Fainting with changes in position (orthostatic intolerance)
Celiac Artery Compression Syndrome:
The main symptoms of this syndrome include chronic abdominal pain, abdominal pain after eating, weight loss, and sometimes a feeling of abdominal noise or congestion. Compression syndrome may be the cause of persistent abdominal pain that is not successfully treated. However, this condition is usually not life-threatening, but can negatively affect quality of life. People with these symptoms should consult a specialist vascular surgeon.
General Symptoms and Effects:
Median arcuate ligament syndrome and celiac artery compression syndrome are usually not associated with specific symptoms. Symptoms usually present as mild to severe upper abdominal pain, indigestion, nausea, vomiting and constipation or diarrhoea.
The abdominal pain associated with MALS usually worsens during digestion, because the blood flow required for digestion is increased. These symptoms can cause people to reduce their food intake and lead to weight loss. Exercise-induced abdominal pain can also occur and this can lead to exercise intolerance.
You may also hear a buzzing in the epigastric region caused by turbulent blood flow from a narrowed blood vessel.
Among these symptoms, it is important to consult a specialist, especially if you experience prolonged and unexplained stomach pain or abdominal discomfort. A qualified doctor will take the necessary steps to make the correct diagnosis and assess appropriate treatment options.
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Celiac Artery Compression Syndrome Diagnosis
The diagnosis of Celiac Artery Compression Syndrome is based on clinical findings and confirmed by imaging techniques of celiac artery compression. In the diagnostic phase, it is also important to exclude more common causes of abdominal pain, so other conditions such as gastroesophageal reflux disease, chronic gastritis, cholecystitis, inflammatory bowel disease or peptic ulcer disease are examined.
Diagnostic Methods:
This test is used to assess blood flow in the celiac artery. If celiac artery compression is suspected, this test detects a typically high blood flow velocity in the celiac artery. Changes in velocity during deep breathing and the angle between the aorta and the celiac artery are also determined.
These imaging techniques are used to visualise the characteristic ‘hooking’ under the celiac artery. In some cases, conventional angiography may also be preferred, but this is an invasive procedure.
This test involves injection of local anaesthetic and/or corticosteroids into the nerves and celiac ganglion underlying the celiac artery. This test can be performed during MALS surgery to identify those who would benefit most from removal of the celiac plexus.
The diagnosis is usually confirmed by imaging tests in conjunction with clinical symptoms, so that appropriate treatment options can be determined.
Celiac Artery Compression Syndrome Treatment Options and Surgey
The standard treatment of Celiac Artery compression syndrome involves the release of the celiac artery through open surgical or laparoscopic removal of the median arcuate ligament and ganglionic tissue surrounding or completely covering the celiac artery.
These operations are performed by separation of the muscle fibres from the median arcuate ligament and surgical removal of the overlying lymphatic, ganglionic and soft tissue.
The term neurolysis refers to the removal of nerve and ganglion tissue surrounding the anterior, lateral and posterior parts of the artery. In some cases, inflammation and scar tissue may also be removed. Three main types of surgery are available to respond to treatment: open surgery, laparoscopic and endovascular methods.
Details of the Open Surgical Approach:
The open surgical approach is a commonly used method for the release of the median arcuate ligament. This method is usually performed using an incision in the epigastric region. The incision is usually made to cover two-thirds of the distance between the lower end of the sternum and the umbilical wound.
The surgeon exposes the area between the stomach and the liver, exposing the median arcuate ligament. Using a combination of sharp dissection, the celiac artery is circumferentially freed from the partially removed muscle and ganglionic tissue.
After the artery is released, intraoperative duplex arterial ultrasound is obtained to determine whether the artery is not severely narrowed or occluded. In cases of severe narrowing, a small prosthetic patch or graft can be placed for immediate repair of the artery.
The main advantages of the open surgical approach are based on the safety of surgical dissection under direct vision and the ability to intervene in any small tear or bleeding area.
This approach also allows complete and circumferential release of the artery, including the tissue located behind the celiac artery. Furthermore, any severe narrowing can be repaired immediately.
The main disadvantage is that an incision is made and a larger area is needed. Therefore, it is important that surgeons carefully consider this method when choosing it and apply it to appropriate patients.
Features of the Laparoscopic Approach:
Laparoscopic release of the celiac artery requires small holes for insertion of the camera and surgical instruments without a larger incision. This approach is a more minimally invasive method.
The surgeon uses surgical instruments such as scissors and cautery when working with camera visualisation. Basically the same steps are performed, but although the operation has the advantage of smaller incisions, there are potential disadvantages, such as the risk of bleeding complications or less complete release of the ligament.
For the laparoscopic approach to be successful, it is important that it is performed by a surgeon who has extensive experience with laparoscopy and is familiar with surgical dissection of the celiac artery. Furthermore, if laparoscopy is chosen, the procedure should be performed in a surgical setting and by a team that can perform arterial repair if necessary. This is critical for successful completion of the operation.
Features of the Endovascular Approach:
The endovascular approach is not recommended as a stand-alone treatment of celiac artery compression syndrome. This approach is usually used in cases where the muscle and connective tissue that can cause permanent compression of the artery cannot be surgically released.
Endovascular treatment involves balloon angioplasty and stent placement to open the celiac artery. However, in cases where the ligament has not been previously surgically released, patients treated with angioplasty and stenting may be at risk of complete blockage or breakage of the stent due to compression of the median arcuate ligament.
Therefore, in most cases, the endovascular approach is used following previous laparoscopic or open surgical release to treat the remaining narrowing of the artery. In this case, the procedure can be performed under local anaesthesia by making a small puncture in the inguinal artery. A catheter is inserted into the celiac artery and the narrowing is widened by balloon angioplasty. Typically, a stent is also placed.
In conclusion, the endovascular approach plays a complementary role to surgical treatment and is used to widen the narrowing in the artery. However, prior surgical release may be required for this method to be effective.
Frequently Asked Questions About Celiac Artery Compression
What is celiac artery outlet?
The celiac artery or celiac artery originates from the abdominal aorta, the largest artery in the body, and carries blood pumped from the heart to various organs of the abdomen. These organs include the duodenum and upper part of the pancreas, liver, stomach, abdominal oesophagus and spleen. In the human body, the celiac artery arises from the upper edge of the L1 vertebra.
What is MALS disease?
MALS (median arcuate ligament syndrome) is a condition in which the celiac artery is compressed by the median arcuate ligament of the diaphragm in the proximal part of the celiac artery where it originates from the aorta, resulting in reduced blood flow in the gastrointestinal tract or ischaemic (blood deficiency) condition. The most prominent symptom of this condition is abdominal pain after a meal.
Can celiac disease be detected on ultrasound?
Yes, the presence and condition of the celiac artery can be determined by ultrasound. Colour Doppler ultrasound of the celiac artery usually begins with a transverse scan of the proximal abdominal aorta. During this scan, a T or ‘seagull’ appearance is obtained, showing the bifurcation of the hepatic and splenic branches. The presence and condition of the celiac artery can be assessed by this method.
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