Celiac axis syndrome. Abdominal angina caused by external compression of the celiac artery

First description of a histopathologic grading system and relationship to outcomes after robotic median arcuate ligament release with celiac ganglionectomy and lymphadenectomy

BACKGROUND

Two dominating theories regarding median arcuate ligament syndrome include vascular and neurogenic etiologies from celiac artery and ganglion compression, respectively. Celiac ganglionectomy is not routine during surgery, and specimens are rarely excised; therefore, the extent of nerve involvement and histopathology are unknown. Our study aims to characterize histopathologic findings in median arcuate ligament syndrome, establish a histopathologic grading system, and correlate with clinical outcomes.

METHODS

Robotic median arcuate ligament release, celiac ganglionectomy, and lymphadenectomy were performed with specimens excised and stained using hematoxylin & eosin, trichrome, and S100. Neurofibrosis, adiposity, and reactive changes were described, a grading scale was developed, and results were analyzed with clinical outcomes.

RESULTS

Fifty-four patients were evaluated, of whom 36 met inclusion criteria (81% female, 34.9 [25.9-47.5] years, body mass index 23.5 [19.6-28.1] kg/m2). Histopathologic evaluation revealed fibrosis (hematoxylin & eosin and trichrome median score 1.5 [0-2.5]), reactive lymphadenopathy (89%), intraparenchymal nerves (31%), and lipogranulomas (31%). Greater fibrosis was associated with a lack of preoperative celiac plexus block relief (100% vs. 30%, P = .044) and lower postoperative celiac artery velocities (198 vs 323 cm/s, P = .02). Intraparenchymal nerves were associated with greater decreases in pre to postoperative velocities (161 vs 84 cm/s, P = .037). Symptoms improved in 28 patients (78%).

CONCLUSION

We developed the first histopathologic grading system and identified unique findings of intraparenchymal nerves and lipogranulomas. Histopathologic abnormalities were associated with objective improvement and symptomatic relief postoperatively. These findings support nerve compression and inflammation as predominant contributors to median arcuate ligament syndrome pain, celiac ganglia resection to treat symptoms, and continued histopathologic analysis to better elucidate median arcuate ligament syndrome etiology.

Median arcuate ligament syndrome in an old male: a case report with 3-year follow-up

Introduction and importance

Median arcuate ligament syndrome (MALS) or Dunbar syndrome is a rare compression syndrome that poses a challenge to many clinicians due to its ambiguous symptoms. It is predominantly common in females in their 30s to 50s.

Case presentation

A 74-year-old male presented with generalized chronic postprandial abdominal pain, anorexia, and weight loss of 6 kg for the past 2 months. Physical examination, abdominal ultrasound, endoscopy, and colonoscopy were all unremarkable. His laboratory workup and tumor marker tests were within normal ranges. Finally, a multi-slice computed tomography (MSCT), an advanced computed tomography with multiple detectors resulting in faster and higher resolution imaging, outlined external compression on the celiac artery (CA) by the median arcuate ligament (MAL). The release of the CA from the MAL was done laparoscopically. Symptoms improved significantly postoperatively. During the follow-up period of 3 years, the patient did not regain his lost weight but had no other complaints.

Clinical discussion

Due to its vague manifestations, MALS is diagnosed only after extensive evaluation and exclusion. This challenging diagnosis outlines the need for refined diagnostic guidelines. An MSCT plays a crucial role in confirming the diagnosis. Currently, more physicians prefer laparoscopic release of the MAL compared to an open approach.

Conclusion

Despite MALS predominance in females, the diagnosis of MALS should be considered in males with postprandial abdominal pain and unexplained weight loss. An MSCT, along with other imaging modalities, can provide a comprehensive view of celiac compression. Laparoscopic decompression of the CA is an ideal treatment option.

Precise diagnosis and successful surgical intervention of the median arcuate ligament syndrome: A case report

INTRODUCTION AND IMPORTANCE

The median arcuate ligament syndrome (MALS) is a rare disorder that produces a spectrum of symptoms due to compression of the arcuate ligament, clinically manifested primarily by abdominal pain, nausea, vomiting, and weight loss. The mechanism of these symptoms has not yet been revealed, and the current treatment methods are still somewhat controversial.

CASE PRESENTATION

We present a 54-year-old woman who presented with intermittent epigastric pain for nine months. During the onset, she lost 7.5 kg. After routine examinations in a nearby hospital, no abnormality was found. She was referred to us. CTA showed compression of the celiac artery. Further selective celiac angiography at the end of inspiration and expiration confirmed MALS. After consultation with the patient, the decision to have a laparotomy was made. The celiac artery was completely skeletonized, and external compression on the artery was released. Postoperative symptoms improved significantly. One-year follow-up after the operation, she had a weight gain of 4.8 kg and was satisfied with the surgical results.

CLINICAL DISCUSSION

The manifestations of MALS are varied and challenging. Our patient presented with weight loss and intermittent abdominal pain. The mutual confirmation of multiple investigations can provide a more comprehensive overview of celiac artery compression. We confirmed using ultrasonography, CT angiography, and selective digital subtraction angiography in this case. The celiac artery compression was relieved after open surgery. Our patient's symptoms improved significantly after surgery. We hope our treatment method can provide a reference for MALS diagnosis and treatment.

CONCLUSION

It is challenging to diagnose MALS. Cross-confirmation of multiple examinations can provide a more comprehensive view of celiac compression. Surgical decompression of the celiac artery (open or laparoscopic surgery) may be an effective therapy for MALS, especially in centers with experience.

A nationwide analysis of median arcuate ligament release between 2010 and 2020: a NSQIP Study

BACKGROUND

Median arcuate ligament syndrome is a rare disease with overlapping symptoms of broad foregut pathology. Appropriately selected patients can benefit from a laparoscopic or open median arcuate ligament release. Institutional series have reported the outcomes of open and laparoscopic techniques but there are no nationwide analysis comparing both techniques and overall trends in treatment.

METHODS

Cross-sectional study using the American College of Surgeons-National Surgical Quality Improvement Project from 2010 to 2020. Celiac artery compression syndrome cases were identified by International Classification of Diseases (ICD) codes and categorized as open or laparoscopic. Trends in the use of each technique and 30-day complications were compared between the groups.

RESULTS

A total of 578 open cases (76%) and 185 laparoscopic cases (24%) were identified. There was an increase adoption of the laparoscopic approach, with 22% of the cases employing this technique at the end of the study period, compared to 7% at the beginning of the study period. The open group had a higher prevalence of hypertension (26% vs 18%, p = 0.04) and bleeding disorders (5% vs 2%, p 0.03). Laparoscopic approach had a shorter length of stay (2.3 days vs 5.2 days, p < 0.0001), lower major complication rates (0.5% vs 4.0%, p = 0.02) and lower reoperation rates (0% vs 2.6%, p = 0.03). Overall mortality was 0.1%.

CONCLUSION

Overall numbers of surgical intervention for treatment of median arcuate ligament increased during this timeframe, as well as increased utilization of the laparoscopic approach. It appears to be an overall safe procedure, offering lower rates of complications and shorter length of stay.

Robotic versus laparoscopic median arcuate ligament (MAL) release: a retrospective comparative study

BACKGROUND

Multiple retrospective studies have demonstrated the safety and feasibility of laparoscopic median arcuate ligament division with celiac neurolysis for the definitive management of median arcuate ligament syndrome (MALS). This study queries the clinical equipoise of robotic (RMALR) versus laparoscopic MAL release (LMALR) at a high-volume center.

METHODS

A retrospective analysis of consecutive 26 RMALR and 24 LMALR between March 2018 and August 2019 by a single surgeon at a quaternary academic institution was completed. Primary endpoint was postoperative decrease in celiac trunk expiratory peak systolic velocities (PSVs) measured by mesenteric duplex ultrasonography. Secondary outcomes included reported improvement in MALS-related clinical symptoms, distribution of first assistant seniority level, and involvement of second assistants in RMALR versus LMALR.

RESULTS

Mean operative times for LMALR and RMALR were 86 and 134 min, respectively (p < 0.0001). There were no open conversions and mean length of hospital stay was 1 day for both cohorts. Both groups provided an equally effective decrease in postoperative peak systolic velocities (PSVs) (LMALR p = 0.0011; RMALR p = 0.0022; LMALR vs. RMALR p = 0.7772). While RMALR had significantly higher reduction of chronic abdominal pain postoperatively, there were no significant differences in other postoperative symptom relief between groups. However, RMALR patients reported significant relief of postprandial abdominal pain (p < 0.0001) and chronic nausea (p = 0.0002). RMALR had significantly more junior first assistants (p = 0.0001) and less frequently required second assistants compared to LMALR (p = 0.0381).

CONCLUSIONS

In this study comparing RMALR to LMALR, postoperative chronic abdominal pain relief was significantly less in the former while other outcomes were equivalent. In comparison with LMALR, RMALR cases were associated with more junior first assistants, fewer second assistants, and longer operative times. Both approaches are safe and feasible for well-selected patients in experienced centers.

Clinical Response to Celiac Plexus Block Confirms the Neurogenic Etiology of Median Arcuate Ligament Syndrome

PURPOSE

To evaluate the response of median arcuate ligament syndrome (MALS) symptoms, including postprandial pain, nausea, and vomiting, to celiac plexus block (CPB) and correlate the response with arterial anatomy.

MATERIALS AND METHODS

In a single-institution, retrospective cohort of clinically diagnosed MALS patients, 96 patients (female, 75; male, 21; mean age, 27 years) underwent 103 computed tomography‒guided percutaneous CPB procedures. Imaging, procedural, and clinical reports were reviewed. Primary outcomes evaluated were technical success, change in self-reported pain score, and change in nausea and vomiting.

RESULTS

Computed tomography imaging before the procedure was available for 81 of 96 patients and demonstrated findings of celiac artery compression in 22 of 81 (27%) patients. Technical success was achieved in 102 of 103 cases. No major adverse events and 1 moderate adverse event were reported. The postprandial pain score decreased in 86 (84%) patients, and the mean score decreased from 6.3 to 0.9 points (P < .001). The prevalence of postprandial nausea decreased from 37.9% to 11.6% (P < .001) and that of vomiting decreased from 15.5% to 4.9% (P = .019). No differences were noted in pain relief after CPB between patients with and without celiac artery compression (P = .745).

CONCLUSIONS

In patients with a clinical diagnosis of MALS, a large majority reported pain relief and decreased gastrointestinal symptoms after CPB. Pain relief did not correlate with the presence of celiac arterial abnormalities. This supports neuropathy as the primary etiology of MALS and suggests that the absence of celiac stenosis should not be used as an exclusion criterion.

Clinico-pathologic findings in patients with median arcuate ligament syndrome (celiac artery compression syndrome)

Median Arcuate Ligament Syndrome (MALS) is a rare entity characterized by severe post-prandial epigastric pain, nausea, vomiting, and/or weight loss. Symptoms have been attributed to vascular compression (celiac artery compression syndrome, CACS), but it remains controversial whether they could be secondary to neural compression. Literature review identified rare description of pathologic findings in surgery journals. The clinico-pathologic findings of four MALS patients who underwent robotic or laparoscopic surgery in our hospital are described. All our patients were female with a median age of 32.5 (range 25-55 years), and a median BMI of 23.5 kg/m². They presented with chronic often post-prandial abdominal pain (4/4), nausea (3/4), emesis (2/4), anorexia (1/4), and weight loss (1/4). Two patients had a history of Crohn's disease. At intraoperative exploration, the celiac artery and adjacent nerves and ganglia were encased and partially compressed by fibrotic tissue in each patient. In each case laparoscopic excision of fibrotic tissue, celiac plexus and ligament division and was performed; celiac plexus nerve block was also performed in one patient. After surgical intervention, symptoms improved in three of the patients whose specimens show periganglionic and perineural fibrosis with proliferation of small nerve fibers. Our findings support neurogenic compression as a contributing factor in the development of pain and other MALS symptoms, and favor the use of MALS rather than CACS as diagnostic terminology. To further study the pathogenesis of this unusual syndrome, surgeons should submit all tissues excised during MALS procedures for histopathologic examination.

Median arcuate ligament syndrome in the pediatric population

OBJECTIVES

Median arcuate ligament syndrome (MALS) is a vascular compression syndrome with symptoms that overlap chronic functional abdominal pain (CFAP). We report our experience treating MALS in a pediatric cohort previously diagnosed with CFAP.

PATIENTS AND METHODS

We prospectively evaluated 46 pediatric (<21years of age) patients diagnosed with MALS at a tertiary care referral center from 2008 to 2012. All patients had previously been diagnosed with CFAP. Patients were evaluated for celiac artery compression by duplex ultrasound and diagnosis was confirmed by computed tomography. Quality of life (QOL) was determined by pre- and postsurgical administration of PedsQL™ questionnaire. The patients underwent laparoscopic release of the median arcuate ligament overlying the celiac artery which included surgical neurolysis. We examined the hemodynamic changes in parameters of the celiac artery and perioperative QOL outcomes to determine correlation.

RESULTS

All patients had studies suggestive of MALS on duplex and computed tomography; 91% (n=42) positive for MALS were females. All patients underwent a technically satisfactory laparoscopic surgical release resulting in a significant improvement in blood flow through the celiac artery. There were no deaths and a total of 9 complications, 8 requiring a secondary procedure; 33 patients were administered QOL surveys. 18 patients completed the survey with 15 (83%) patients reporting overall improvement in the QOL. Overall, 31/46 patients (67%) reported improvement of symptoms since the time of surgery.

CONCLUSIONS

MALS was found to be more common in pediatric females than males. Laparoscopic release of the celiac artery can be performed safely in the pediatric population. Surgical release of the artery and resultant neurolysis resulted in significant improvement in the blood flow, symptoms, and overall QOL in this cohort. The overall improvement in QOL outcome measures after surgery leads us to conclude that MALS might be earlier diagnosed and possibly treated in patients with CFAP. We recommend a multidisciplinary team approach to care for these complex patients.

Celiac artery compression syndrome: a radiological finding without clinical symptoms?

The aim of the paper is to determine the incidence of celiac artery compression (CAC) based on computed tomography (CT) scan and correlate the findings to the clinical presentation of patients presenting for CT scan in a hospital. Abdominal CT scans of patients were reviewed between September 2010 and November 2010. CAC was diagnosed if the celiac axis appeared to have a hook or U-shaped appearance with stenosis. The medical records of the patients were reviewed for gastrointestinal symptoms (abdominal pain, nausea, vomiting, constipation, diarrhea), as well as food fear and weight loss. Patients with CAC had lower incidence of symptoms compared with those without CAC (42.1 versus 65.3%, P = 0.042). A total of 450 patients were evaluated. In the end, 284 had both complete medical records and CT scans. The mean age for all patients was 51.3 ± 1.2 years. There were 124 men (42.6%) and 160 (57.4%) women. Nineteen (6.7%) patients had radiological evidence of CAC. CAC is not an uncommon CT finding in patients presenting for CT scan.

Subject body mass index affects Doppler waveform in celiac artery by duplex ultrasound

OBJECTIVE

The aim of this study is to evaluate the effect of body mass index (BMI) on peak systolic velocity (PSV) recording in the celiac artery (CA).

SUBJECTS & METHODS

Forty male participants were entered prospectively into the study. The subjects were divided into two groups according to their body mass index. Group A included subjects with BMI ≤25 Kg/m(2) and those in group B with BMI >25 Kg/m(2). The diameter and PSV at the origin of CA of subjects in both groups were recorded while the subject positioned in supine and during expiration phase and fasted for 4 hours using duplex ultrasound. Both groups were matched for age and sex. Independent Student's t-test was used to test if there is any statistical significance between diameter and PSV in both groups.

RESULTS

Group A's, average age (year, ±SD) was 29.35±1.35 and average BMI (Kg/m(2), ±SD) was 23.1±1.60. Group B's, average age was 30±2.1 and their average BMI was 31±5.1. The average diameter (cm, ±SD) of CA in group A was 0.66±0.076 and in group B was 0.80±0.066. However, the average PSV (cm/s, ±SD) was 117±28.1 in group A and 102±12.4 in group B. Independent student t-test showed statistical significance between both groups for the diameter (p=0.005) and just reached statistical significance for PSV (p=0.049).

CONCLUSION

Subjects with higher BMI showed reduced PSV due to a larger CA diameter and probably due to more fatty tissue accumulation around the CA origin.

Retroperitoneal endoscopic release in the management of celiac artery compression syndrome

INTRODUCTION

Celiac artery compression syndrome (CACS) can be treated successfully by division of the median arcuate ligament and celiac plexus fibers. The standard technique is the open approach by an upper midline or left subcostal incision. Only six single cases in which a laparoscopic transabdominal approach for CACS was used have been reported. We prospectively evaluated the feasibility of the endoscopic retroperitoneal approach for treatment of CACS.

METHODS

All patients with symptoms suggestive of CACS were evaluated using splanchnic duplex ultrasound scanning, gastric exercise tonometry (GET), and multiplane selective splanchnic angiography. The criteria for treatment were chronic abdominal symptoms, respiratory-dependent CA stenosis, and abnormal GET result. The release was performed by a retroperitoneal endoscopic approach. Anatomic success of the procedure was confirmed by angiography.

RESULTS

The endoscopic retroperitoneal approach was used to treat 46 patients with CACS. One patient (2%) required conversion to an open procedure due to suprarenal artery bleeding. Release was ended prematurely in one patient due to a pneumothorax resulting in loss of working space. A postoperative pneumothorax developed in two patients, of which one needed treatment. No other complications were observed. Postoperative angiography during inspiration and expiration showed normal vessel anatomy in 36 of 46 patients. Six of 10 patients with persisting intraluminal stenoses were treated endovascularly. Five of these were successful, which brings the primary-assisted anatomic patency for the total group to 89% (41 of 46 patients). Three patients are being observed, and endovascular treatment remains an option in case of insufficient improvement. On median follow-up of 20 months (range, 2-42 months) 41 patients were free of symptoms or showed significant improvement.

CONCLUSIONS

The endoscopic retroperitoneal approach for the release of the CA in CACS, with additional endovascular treatment of persistent stenosis, is feasible and effective. Short-term results were comparable with the open procedure.

A case of severe compression of the coeliac artery

A man, aged 42 years, presented as an emergency with a history of stabbing upper abdominal pain, nausea and diarrhoea of two weeks' duration. Apart from abnormal transaminase and alkaline phosphatase values, the routine clinical and laboratory examinations did not reveal any abnormality. As the abdominal pain increased in severity, particularly in association with eating, and projectile vomiting supervened, aortography was carried out and showed severe stenosis of the coeliac axis, involving about 1 cm of the artery. At operation a thick fibrous band, which originated from the median arcuate diaphragm, was seen to constrict the point of origin of the artery and to compress the vessel against the aorta. The band was divided, whereupon the coeliac artery immediately showed strong pulsations and adequate filling. Microscopic examination of the fibrous band revealed, among other structures, those characteristic of a ganglion. The symptoms disappeared after operation.

Clinical anatomy of celiac artery compression syndrome: a review

Anatomic variations are often responsible for a variety of clinical conditions. In this review we investigate compression of the celiac artery and the superior mesenteric artery by the median arcuate ligament (MAL), diaphragmatic crura, or the celiac nerve plexus. This clinical condition known as celiac artery compression syndrome (CACS) has proven controversial in definition and relevance. This condition was first described as chronic abdominal pain because of the mesenteric ischemia caused by extrinsic compression of the celiac artery. Dunbar and others presented surgical approaches to decompress the celiac artery by releasing the MAL. Definitive answers have been sought to classify and relieve the clinical symptoms patients experience postprandially. Persistent symptoms following surgical treatment for CACS have led investigators to question the existence of this disease. Advances in technology such as angiographic MRI and color duplex ultrasonography have refreshed the importance of considering compression of the celiac artery during differential diagnoses. Because of the varying anatomic etiologies of disease, it is not possible to pinpoint a single cause for CACS. Potential etiologies for compression of the celiac artery include a "high take off" origin of the celiac artery compressed by normal diaphragmatic crura and MAL, a normal origin of the celiac artery with long diaphragmatic crura and MAL, large bilaterally fused celiac ganglia (with or without the involvement of the superior mesenteric ganglia) compressing the celiac trunk, celiacomesenteric trunk compression by diaphragmatic crura and MAL, or combinations of the above mentioned entities. In this review we describe potential sources of compression of the celiac artery by regional structures and treatments of CACS in an effort to justify the relevance of CACS in modern medicine.

Reversible Gastroparesis: Functional Documentation of Celiac Axis Compression Syndrome and Postoperative Improvement

Celiac axis compression syndrome has generated much controversy since its original description in 1963. The main symptoms are postprandial epigastric abdominal pain, regurgitation of undigested food, and weight loss, all of which are caused by gastric ischemia from impingement of the celiac axis by the median arcuate ligament of the diaphragm. These symptoms are seen in other common disorders such as chronic mesenteric ischemia and gastroparesis. This makes the diagnosis of celiac axis compression syndrome a true challenge for the clinician. We present data on three patients successfully treated. The pre- and postoperative studies clearly demonstrate a resolution of the condition. The duplex ultrasound images clearly show variable compression on the celiac axis. The angiogram presented shows a classic image of the disease. A review of the data has enabled us to develop an algorithm for the diagnosis of this disease.

Celiac artery compression syndrome in children, adolescents, and young adults: clinical and color duplex sonographic features in a series of 59 cases

OBJECTIVE

Abdominal pain is one of the most common conditions in childhood and adolescence. Celiac artery compression syndrome (CACS) is rarely suspected in this population. We present clinical and sonographic features from a series of 59 patients with this disorder.

METHODS

A total of 3449 patients from 0 to 18 years were investigated with 7639 abdominal color duplex sonographic examinations. Celiac artery flow velocity was measured at the branching off from the aorta in inspiration, expiration, and in between. Diagnosis of CACS was made if a greater than 2-fold acceleration of peak systolic flow in the celiac artery compared to the abdominal aorta or a peak systolic velocity greater than 200 cm/s was measured in the mid position and if a variation of flow velocity occurred during respiration. In 22 cases, angiography (21 magnetic resonance angiography and 1 digital subtraction angiography) was used to prove sonographic diagnosis.

RESULTS

Fifty-nine patients (among them 81% female) from 22 months to 19 years (clustering between 14 and 17 years) fulfilling color Doppler sonographic criteria of CACS were found, for a prevalence of 1.7%. Their symptoms included, among others, abdominal pain (71%), nausea (29%), thoracic pain (22%), heartburn (17%), weight loss (15%), vomiting (15%), systolic murmur (15%), postprandial accentuation of symptoms (15%), diarrhea (14%), respiratory discomfort (14%), and syncope (12%).

CONCLUSIONS

Celiac artery compression syndrome is more prevalent than expected, and conditions not usually connected to the disease were found. Alertness to CACS is recommended, especially in patients with a combination of characteristic symptoms. Color Doppler sonography is the modality of choice for diagnosing CACS.

Mitral valve prolapse associated with celiac artery stenosis: a new ultrasonographic syndrome?

BACKGROUND

Celiac artery stenosis (CAS) may be caused by atherosclerotic degeneration or compression exerted by the arched ligament of the diaphragm. Mitral valve prolapse (MVP) is the most common valvular disorder. There are no reports on an association between CAS and MVP.

METHODS

1560 (41%) out of 3780 consecutive patients undergoing echocardiographic assessment of MVP, had Doppler sonography of the celiac tract to detect CAS.

RESULTS

CAS was found in 57 (3.7%) subjects (23 males and 34 females) none of whom complained of symptoms related to visceral ischemia. MVP was observed in 47 (82.4%) subjects with and 118 (7.9%) without CAS (p < 0.001). The agreement between MVP and CAS was 39% (95% CI 32-49%). PSV (Peak Systolic Velocity) was the only predictor of CAS in MPV patients (OR 0.24, 95% CI 0.08-0.69) as selected in a multivariate logistic model.

CONCLUSION

CAS and MVP seem to be significantly associated in patients undergoing consecutive ultrasonographic screening.

Celiac artery compression syndromes

Compression of the visceral arteries can produce true mesenteric ischemia, but the syndrome is rare. The syndrome is caused by unfavorable anatomic relationships at the aortic hiatus among the CA, the SMA, and overlying structures, particularly the diaphragmatic crura. These anatomic relationships, in contrast to the syndrome they sometimes produce, are relatively common, which makes the detection of CA compression only a prerequisite to the diagnosis of the clinical entity. The diagnosis of CA compression syndrome ultimately depends on the relentless elimination of other possible causes for abdominal pain and on the knowledge that this curious syndrome does indeed exist. If properly diagnosed, the CA compression syndrome can be corrected with a safe, relatively simple surgical procedure. Past treatment series reflect too little appreciation for the extensiveness of a true, chronic CA injury. Revascularization of the CA, in addition to release of compression, should therefore be performed with greater frequency in the future. The young patients who are successfully diagnosed and treated for this unusual syndrome are frequently entirely relieved of long-standing, debilitating pain, and, like other patients with chronic mesenteric ischemia, they typically enjoy dramatic improvement in the quality of their lives. Thus, with the prospect of these patients in mind, a clinician should accept the opinion that the syndrome "does not exist" only after careful consideration of the entire literature.

Would you recognize celiac axis syndrome?

Since its original description, celiac axis syndrome has been a topic of debate. Clinical findings include postprandial abdominal pain, weight loss, and an epigastric bruit. Diagnosis is often made by exclusion and is confirmed by lateral aortography. The role of surgery in treating celiac axis syndrome is controversial.

[Compression of the celiac trunk (author's transl)]

Besides the vascular changes caused by arteriosclerosis the compression stenosis is the most frequent form of the isolated restriction of the arteria coeliaca. The compression of the arteria coeliaca, caused by the ligamentum arcuatum medianum or a fribromatous ganglion tissue, can cause complaints similar to the symptoms of angina abdominalis: pains in the epigastrium, postprandial pains, loss of weight, nausea/vomiting, diarrhea, 93% of the patients with severe vascular compression have an abdominal vascular murmur. Of 31 patients with angiographically proved compression stenosis, 11 patients suffering from occlusion or intense stenosis had to be operated because of heavy complaints. The angiographic and intraoperative findings allow the conclusion that there is a connection between the extent of the stenosis and the clinical appearance. The decompression of the arteria coeliaca, in other words the detachment of the compressing tissue leads to total complaintlessness in 83% of the patients. If the arteria coeliaca is hypoplastic a vessel widening or a bypass operation is necessary to establish normal blood circulation in the epigastric organs.

Median arcuate ligament compression of the celiac and superior mesenteric arteries

Images

Experience with coeliac axis compression syndrome

Seven patients with "coeliac axis compression syndrome" are reported. Five were treated surgically, but only two did well. A survey of 200 healthy adults showed epigastric bruits in 6.5%; only one of these had dyspepsia, though dyspepsia was present in 12.5% overall.Caution is urged in attributing a causal relationship between coeliac axis compression and pain and in proceeding to arteriography when compression is suspected on clinical grounds.

Vascular radiology in liver disease

Vascular radiology of the liver has increased in scope and function in recent years due mainly to the application of new techniques.

It is now possible to examine not only the inferior vena cava and the portal venous system, but also the hepatic veins and the coeliac axis and superior mesenteric artery. Hepatic vein occlusion, portal vein patency and collateral veins, as well as space-occupying lesions, can now be diagnosed with a fair degree of accuracy.

These techniques have also helped in the understanding of the altered haemodynamics of portal hypertension and can be used for treatment by intra-arterial perfusion of chemotherapeutic substances.