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Only for medical professionals to read for reference, right lower abdominal pain, it may also be it.
In their daily work, gastroenterologists encounter patients with abdominal pain the most.
The abdominal pain that causes physicians the most headache is the biochemical indicators.
The ultrasound of liver, gallbladder, pancreas, spleen and kidney is normal, and it is patients with abdominal pain for several months; it makes doctors want to hit the wall.
Abdominal pain is normal in all biochemical indicators, tumor markers, gastroscopy, colonoscopy, and ultrasound.
The patient still has abdominal pain after empirical use of drugs to promote gastrointestinal motility.
Today, what I want to share with you is such a case of abdominal pain that makes people headache.
Case brief introduction A 50-year-old female patient has had no obvious cause of intermittent abdominal pain in the right lower abdomen for the past 2 months, has nothing to do with diet, no vomiting, no diarrhea, no blood in the stool.
Seeing pain in the right lower abdomen, I believe that most doctors think of appendicitis, cholecystitis, liver disease, etc.
, relatively rare such as diverticulitis, mesenteric panniculitis, etc.
The patient had been in the local hospital one month ago, and the blood routine, liver and kidney function tests were normal, and the ultrasound examinations were also normal.
After all, it was an examination one month ago.
In this visit, there must be a lot of blood routines and liver and kidney function.
It may be a tumorous disease, and there must be no less tumor markers.
A set of enhanced CT of the abdomen and pelvis is also available.
I believe that as long as there are inflammatory and space-occupying lesions in the abdominal and pelvic cavity, they will never escape these inspections.
However, seeing the results of biochemical examinations makes people head overwhelmed: blood routines are normal, liver and kidney function, apolipoprotein are normal, tumor markers are normal, and ultrasound examination of the liver, gallbladder, pancreas, spleen and kidney is also normal.
Finally, let’s take a look at the important images of abdominal and pelvic enhanced CT (axial, sagittal, and VRT images): The axial image of the patient’s axial sagittal VRT image below the opening of the abdominal artery adjacent to the main celiac artery, Observing the lesion is relatively difficult.
However, on the sagittal image, the compression at the beginning of the abdominal cavity shows a fishhook-like stenosis.
On the VRT image, because the VRT image uses a thick layer of VRT, the partial volume effect makes it relatively difficult for us to observe the lesion.
If we do not observe carefully , It is difficult to find the lesion.
Therefore, thin-layer VRT processing was performed again.
The arrow points to the compressed and narrow abdominal cavity.
I believe most people already know that this is the cause of the patient's abdominal pain: the middle arcuate ligament compression syndrome.
The following is a detailed introduction to the main points of the disease.
Understand the middle arcuate ligament syndrome (median arcuate ligament syndrome, MALS), also known as celiac artery compression syndrome, diaphragm middle foot compression syndrome, etc.
The median arcuate ligament is the connection between the two aortic hiatus The fibrous ligament of the lateral diaphragm constitutes the anterior edge of the aortic hiatus.
The trunk artery of the celiac is mostly sent out slightly below the middle arch ligament, and then divided into the common hepatic artery, the splenic artery and the left gastric artery, which means that the middle arch ligament is mostly located in the abdominal cavity Dry above.
In the population, 10%-24% of the abdominal trunk is emitted next to the middle arch ligament, which is located at or below the bifurcation of the abdominal trunk.
The opening of the abdominal cavity is too high, and the attachment point of the diaphragm foot is too low, resulting in compression of the abdominal cavity in some patients, which can cause clinical symptoms in severe cases.
MALS was first reported by Harjola in 1963.
The incidence of the disease is about 1.
74%-4.
0%, and it is more common in young women with long and thin body (more common in 20-40 years old).
The incidence ratio of male to female is 1:4.
However, Chinese scholar Zhong Xiaomei and others believe that the disease is not obvious Age and gender differences.
The pathogenesis of middle arcuate ligament compression syndrome The pathogenesis of MALS is still controversial.
Most scholars have the following two views: the theory of compression of the abdominal trunk and the theory of compression of the peritoneal ganglion cells.
(1) The theory of celiac trunk compression: the middle arch ligament compresses the celiac artery and causes stenosis of the lumen, resulting in a decrease in the blood flow of the internal organs in the blood supply area; the compressed celiac trunk collateral artery steals blood from the superior mesenteric artery and causes intestinal ischemia.
Theoretical basis supporting arterial compression: ①The characteristic hook-shaped stenosis of the celiac artery was found by imaging examination, and the expansion after stenosis was found; ②The flow velocity of the celiac artery was significantly increased by ultrasound in the supine position, and deep inhalation or standing position was due to the celiac artery Move down to the side of the foot away from the compression, and the flow rate returns to normal; ③After the loosening of the middle arch ligament and revascularization, the symptoms of most patients disappeared or alleviated.
I personally support the theory of abdominal cavity compression because we can observe the corresponding changes in imaging.
The MALS in the supine position is greatly affected by the breathing movement, and it is also a difficult point in imaging.
In order to let everyone better understand the mechanism of the disease and the imaging changes, the above picture is used to illustrate (the picture above is a supine position, which is consistent with the patient's position during CT and ultrasound examinations).
Breathing can cause the position of the middle arch ligament to move.
When inhaling, the intercostal space widens, the rib cage rises, the diaphragm contracts, and the middle arch ligament diaphragm attachment (including the diaphragm foot) rises accordingly.
When exhaling, on the contrary, the middle arch ligament diaphragm attachment (including the diaphragm foot) descends.
MALS was affected by breathing exercise.
A 47-year-old male patient was diagnosed with MALS.
CTA findings: No obvious stenosis of the celiac artery on the inspiratory scan (arrow), severe stenosis of the celiac artery on the end-expiratory scan (arrow), which was hook-shaped at the end of expiration.
Ultrasonic performance: The flow velocity of the celiac artery in the resting state increased to 278cm/s (normal <180cm/s; the flow velocity of the celiac artery at the end of inhalation returned to normal at 87cm/s; the flow velocity of the celiac artery at the end of expiration was significantly increased to 400cm /s.
(2) The theory of celiac ganglion cell compression: paraesthesia and sympathetic nerve stimulation caused by celiac ganglion compression, nerve insufficiency caused by sympathetic nerve fiber compression, celiac artery occlusion and end-expiratory flow rate changes are nerve compression Signs.
Celiac ganglion block can relieve abdominal pain symptoms.
The clinical manifestations of middle arcuate ligament compression syndrome The middle arcuate ligament compression syndrome occurs more often in thin women aged 20-40, and its typical triad is postprandial Abdominal pain, weight loss, and abdominal vascular murmurs,
but the chances of all three appearing at the same time are low.
It should be noted that: abdominal pain is mainly a state of upper abdominal pain caused by the compression of the middle arch ligament on the abdominal trunk artery and the abdominal ganglion.
Abdominal pain may be related to diet, and may be accompanied by weight loss and bowel sounds.
Imaging manifestations of middle arcuate ligament compression syndrome.
Patients with suspected middle arcuate ligament compression syndrome can be diagnosed mainly from CT examination and ultrasound examination.
DSA can also diagnose MALS.
Because it is an invasive examination, the application is relatively reduced.
▎CT inspection CTA three-dimensional reconstruction can clearly show the location and degree of celiac artery stenosis.
The sagittal view is the best plane for observing the thickened middle arch ligament and characteristic hook stenosis.
The coronal plane is more conducive to showing the collateral artery.
Spatial walking is currently the best imaging method for the diagnosis of MALS.
For patients suspected of MALS, when undergoing an enhanced CT examination, pay attention to the breathing instructions that are different from our examination.
In the end-tidal scan, the compressed celiac artery is more clearly displayed.
At the same time, for patients suspected of the disease, our imaging physicians should pay more attention to observe whether there are thickened ligaments above the opening of the celiac trunk artery and whether the artery is abnormal.
If necessary, perform sagittal observation and reconstruct VRT images.
In normal patients, the upper layer of the abdominal trunk artery and the upper layer of the abdominal trunk in MALS patients ▎Ultrasound color Doppler ultrasound examination If the end-expiratory systolic peak flow rate of the abdominal trunk artery is significantly increased and the end-inspiratory flow rate returns to normal, it may indicate the presence of MALS compression .
It is reported that the peak end-expiratory flow rate>249cm/s and the end-inspiratory or standing position flow rate return to normal are the diagnostic criteria.
▎DSA examination DSA is the "gold standard" for the diagnosis of MALS.
Typical imaging changes include lateral aortic imaging at the end of expiration, showing characteristic hook-shaped stenosis in the initial segment of the celiac artery, dilatation of the distal end, and end-inspiratory stenosis The degree was significantly reduced, and even returned to normal.
DSA is also the only imaging method that can display real-time collateral blood flow from the superior mesenteric artery into the common hepatic artery.
However, it is an invasive examination and cannot show the thickened middle arch ligament, which has certain limitations.
The treatment of middle arcuate ligament compression syndrome is usually surgical hand therapy.
The main method is to loosen the arcuate ligament combined with celiac ganglionectomy.
Among them, surgical release of the middle arch ligament is a classic treatment for MALS, and most patients benefit from surgical treatment.
Reference source: [1] Wang Xianming, Hua Xianping, Zheng Guoliang.
New progress in diagnosis and treatment of middle arch ligament compression syndrome[J].
Chinese Journal of Medical Imaging,2018,26(06):476-480.
[2] Chen Ruxuan,Sun Hao,Xue Huadan,Jin Zhengyu.
Diagnosis and treatment of middle arch ligament compression syndrome[J].
Xiehe Medical Journal,2014,5(03):339-342.
[3],.
Celiac artery compression syndrome [J].
Chinese Journal of Health Care and Medicine, 2012, 14(06): 489-490+493.
In their daily work, gastroenterologists encounter patients with abdominal pain the most.
The abdominal pain that causes physicians the most headache is the biochemical indicators.
The ultrasound of liver, gallbladder, pancreas, spleen and kidney is normal, and it is patients with abdominal pain for several months; it makes doctors want to hit the wall.
Abdominal pain is normal in all biochemical indicators, tumor markers, gastroscopy, colonoscopy, and ultrasound.
The patient still has abdominal pain after empirical use of drugs to promote gastrointestinal motility.
Today, what I want to share with you is such a case of abdominal pain that makes people headache.
Case brief introduction A 50-year-old female patient has had no obvious cause of intermittent abdominal pain in the right lower abdomen for the past 2 months, has nothing to do with diet, no vomiting, no diarrhea, no blood in the stool.
Seeing pain in the right lower abdomen, I believe that most doctors think of appendicitis, cholecystitis, liver disease, etc.
, relatively rare such as diverticulitis, mesenteric panniculitis, etc.
The patient had been in the local hospital one month ago, and the blood routine, liver and kidney function tests were normal, and the ultrasound examinations were also normal.
After all, it was an examination one month ago.
In this visit, there must be a lot of blood routines and liver and kidney function.
It may be a tumorous disease, and there must be no less tumor markers.
A set of enhanced CT of the abdomen and pelvis is also available.
I believe that as long as there are inflammatory and space-occupying lesions in the abdominal and pelvic cavity, they will never escape these inspections.
However, seeing the results of biochemical examinations makes people head overwhelmed: blood routines are normal, liver and kidney function, apolipoprotein are normal, tumor markers are normal, and ultrasound examination of the liver, gallbladder, pancreas, spleen and kidney is also normal.
Finally, let’s take a look at the important images of abdominal and pelvic enhanced CT (axial, sagittal, and VRT images): The axial image of the patient’s axial sagittal VRT image below the opening of the abdominal artery adjacent to the main celiac artery, Observing the lesion is relatively difficult.
However, on the sagittal image, the compression at the beginning of the abdominal cavity shows a fishhook-like stenosis.
On the VRT image, because the VRT image uses a thick layer of VRT, the partial volume effect makes it relatively difficult for us to observe the lesion.
If we do not observe carefully , It is difficult to find the lesion.
Therefore, thin-layer VRT processing was performed again.
The arrow points to the compressed and narrow abdominal cavity.
I believe most people already know that this is the cause of the patient's abdominal pain: the middle arcuate ligament compression syndrome.
The following is a detailed introduction to the main points of the disease.
Understand the middle arcuate ligament syndrome (median arcuate ligament syndrome, MALS), also known as celiac artery compression syndrome, diaphragm middle foot compression syndrome, etc.
The median arcuate ligament is the connection between the two aortic hiatus The fibrous ligament of the lateral diaphragm constitutes the anterior edge of the aortic hiatus.
The trunk artery of the celiac is mostly sent out slightly below the middle arch ligament, and then divided into the common hepatic artery, the splenic artery and the left gastric artery, which means that the middle arch ligament is mostly located in the abdominal cavity Dry above.
In the population, 10%-24% of the abdominal trunk is emitted next to the middle arch ligament, which is located at or below the bifurcation of the abdominal trunk.
The opening of the abdominal cavity is too high, and the attachment point of the diaphragm foot is too low, resulting in compression of the abdominal cavity in some patients, which can cause clinical symptoms in severe cases.
MALS was first reported by Harjola in 1963.
The incidence of the disease is about 1.
74%-4.
0%, and it is more common in young women with long and thin body (more common in 20-40 years old).
The incidence ratio of male to female is 1:4.
However, Chinese scholar Zhong Xiaomei and others believe that the disease is not obvious Age and gender differences.
The pathogenesis of middle arcuate ligament compression syndrome The pathogenesis of MALS is still controversial.
Most scholars have the following two views: the theory of compression of the abdominal trunk and the theory of compression of the peritoneal ganglion cells.
(1) The theory of celiac trunk compression: the middle arch ligament compresses the celiac artery and causes stenosis of the lumen, resulting in a decrease in the blood flow of the internal organs in the blood supply area; the compressed celiac trunk collateral artery steals blood from the superior mesenteric artery and causes intestinal ischemia.
Theoretical basis supporting arterial compression: ①The characteristic hook-shaped stenosis of the celiac artery was found by imaging examination, and the expansion after stenosis was found; ②The flow velocity of the celiac artery was significantly increased by ultrasound in the supine position, and deep inhalation or standing position was due to the celiac artery Move down to the side of the foot away from the compression, and the flow rate returns to normal; ③After the loosening of the middle arch ligament and revascularization, the symptoms of most patients disappeared or alleviated.
I personally support the theory of abdominal cavity compression because we can observe the corresponding changes in imaging.
The MALS in the supine position is greatly affected by the breathing movement, and it is also a difficult point in imaging.
In order to let everyone better understand the mechanism of the disease and the imaging changes, the above picture is used to illustrate (the picture above is a supine position, which is consistent with the patient's position during CT and ultrasound examinations).
Breathing can cause the position of the middle arch ligament to move.
When inhaling, the intercostal space widens, the rib cage rises, the diaphragm contracts, and the middle arch ligament diaphragm attachment (including the diaphragm foot) rises accordingly.
When exhaling, on the contrary, the middle arch ligament diaphragm attachment (including the diaphragm foot) descends.
MALS was affected by breathing exercise.
A 47-year-old male patient was diagnosed with MALS.
CTA findings: No obvious stenosis of the celiac artery on the inspiratory scan (arrow), severe stenosis of the celiac artery on the end-expiratory scan (arrow), which was hook-shaped at the end of expiration.
Ultrasonic performance: The flow velocity of the celiac artery in the resting state increased to 278cm/s (normal <180cm/s; the flow velocity of the celiac artery at the end of inhalation returned to normal at 87cm/s; the flow velocity of the celiac artery at the end of expiration was significantly increased to 400cm /s.
(2) The theory of celiac ganglion cell compression: paraesthesia and sympathetic nerve stimulation caused by celiac ganglion compression, nerve insufficiency caused by sympathetic nerve fiber compression, celiac artery occlusion and end-expiratory flow rate changes are nerve compression Signs.
Celiac ganglion block can relieve abdominal pain symptoms.
The clinical manifestations of middle arcuate ligament compression syndrome The middle arcuate ligament compression syndrome occurs more often in thin women aged 20-40, and its typical triad is postprandial Abdominal pain, weight loss, and abdominal vascular murmurs,
but the chances of all three appearing at the same time are low.
It should be noted that: abdominal pain is mainly a state of upper abdominal pain caused by the compression of the middle arch ligament on the abdominal trunk artery and the abdominal ganglion.
Abdominal pain may be related to diet, and may be accompanied by weight loss and bowel sounds.
Imaging manifestations of middle arcuate ligament compression syndrome.
Patients with suspected middle arcuate ligament compression syndrome can be diagnosed mainly from CT examination and ultrasound examination.
DSA can also diagnose MALS.
Because it is an invasive examination, the application is relatively reduced.
▎CT inspection CTA three-dimensional reconstruction can clearly show the location and degree of celiac artery stenosis.
The sagittal view is the best plane for observing the thickened middle arch ligament and characteristic hook stenosis.
The coronal plane is more conducive to showing the collateral artery.
Spatial walking is currently the best imaging method for the diagnosis of MALS.
For patients suspected of MALS, when undergoing an enhanced CT examination, pay attention to the breathing instructions that are different from our examination.
In the end-tidal scan, the compressed celiac artery is more clearly displayed.
At the same time, for patients suspected of the disease, our imaging physicians should pay more attention to observe whether there are thickened ligaments above the opening of the celiac trunk artery and whether the artery is abnormal.
If necessary, perform sagittal observation and reconstruct VRT images.
In normal patients, the upper layer of the abdominal trunk artery and the upper layer of the abdominal trunk in MALS patients ▎Ultrasound color Doppler ultrasound examination If the end-expiratory systolic peak flow rate of the abdominal trunk artery is significantly increased and the end-inspiratory flow rate returns to normal, it may indicate the presence of MALS compression .
It is reported that the peak end-expiratory flow rate>249cm/s and the end-inspiratory or standing position flow rate return to normal are the diagnostic criteria.
▎DSA examination DSA is the "gold standard" for the diagnosis of MALS.
Typical imaging changes include lateral aortic imaging at the end of expiration, showing characteristic hook-shaped stenosis in the initial segment of the celiac artery, dilatation of the distal end, and end-inspiratory stenosis The degree was significantly reduced, and even returned to normal.
DSA is also the only imaging method that can display real-time collateral blood flow from the superior mesenteric artery into the common hepatic artery.
However, it is an invasive examination and cannot show the thickened middle arch ligament, which has certain limitations.
The treatment of middle arcuate ligament compression syndrome is usually surgical hand therapy.
The main method is to loosen the arcuate ligament combined with celiac ganglionectomy.
Among them, surgical release of the middle arch ligament is a classic treatment for MALS, and most patients benefit from surgical treatment.
Reference source: [1] Wang Xianming, Hua Xianping, Zheng Guoliang.
New progress in diagnosis and treatment of middle arch ligament compression syndrome[J].
Chinese Journal of Medical Imaging,2018,26(06):476-480.
[2] Chen Ruxuan,Sun Hao,Xue Huadan,Jin Zhengyu.
Diagnosis and treatment of middle arch ligament compression syndrome[J].
Xiehe Medical Journal,2014,5(03):339-342.
[3],.
Celiac artery compression syndrome [J].
Chinese Journal of Health Care and Medicine, 2012, 14(06): 489-490+493.
