A Compressed Celiac Artery May Lead to High-Risk Surgery

Allison J. Porter, MD; Robert B. Yates, MD; Joshua M. Mourot, MD; Brant K. Oelschlager, MD

Disclosures

September 11, 2015

Case Presentation

A 44-year-old woman presented with chronic abdominal pain, which was epigastric. In terms of intensity, it varied from a constant dull pain that the patient rated as 7 out of 10 on a visual analogue scale to a sharp pain after meals that she rated as 10 out of 10. She was not taking narcotic pain medications.

Over the course of 1 year, the patient experienced an involuntary 23-lb weight loss. She had undergone upper endoscopy, colonoscopy, hepatobiliary (HIDA) scan, abdominal ultrasound, and upper gastrointestinal fluoroscopy, all of which were normal except for mild nonspecific gastric erythema and a fatty liver. A mesenteric duplex demonstrated a peak celiac expiratory velocity of 371 cm/sec and a peak inspiratory velocity of 283 cm/sec. CT angiography of the abdomen was normal, with the exception of extrinsic narrowing of the celiac axis (Figure 1).

Figure 1. Narrowing of the celiac axis, shown in the sagittal view.

High Prevalence, but Also Rare

Celiac artery compression syndrome, also referred to as "median arcuate ligament syndrome" and "Dunbar syndrome," is a clinical condition in which extrinsic compression of the celiac artery and celiac plexus is associated with abdominal symptoms, such as epigastric pain, nausea, emesis, and weight loss.

The most common cause of celiac artery compression is the median arcuate ligament, the band of tissue that connects the left and right crus of the diaphragm posterior to the esophageal hiatus. Normally, the celiac artery originates below the median arcuate ligament. However, variability in the anatomy of the celiac artery and the median arcuate ligament has been reported.[1] Compression of the celiac artery can result from either a low-lying median arcuate ligament or a celiac artery that exits more cephalad on the aorta. In the general population, celiac artery compression has been found in 10%-24% of patients on CT analysis[2] and in up to 33% of individuals in an autopsy study.[3]

Despite the relatively high prevalence of celiac artery compression, clinically relevant celiac artery compression syndrome is rare. Discordance between the presence of anatomical compression and clinically significant symptoms has led some to question whether the clinical syndrome actually exists.[4] In addition, symptoms of celiac artery compression syndrome are typically chronic and nonspecific, including vague upper abdominal pain, nausea, and emesis. In patients with long-standing symptoms, weight loss may occur owing to decreased oral intake in an attempt to mitigate postprandial symptoms.

Physical examination is generally unremarkable. Careful auscultation may identify an epigastric bruit, but focal abdominal tenderness and peritoneal signs are absent. Patients with celiac artery compression syndrome frequently undergo multiple extensive clinical evaluations before an astute clinician considers this diagnosis.

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