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The median arcuate ligament is a fibrous arch that unites the diaphragmatic crura on either side of the aortic hiatus. The ligament usually passes superior to the origin of the celiac artery near the first lumbar vertebra. In the general population, 10-24% of people may have indentation caused by an abnormally low ligament.¹ Few of these patients have hemodynamically significant stenosis that would cause symptoms. We present the case of a patient with median arcuate ligament syndrome that caused on and off epigastric pain in a thin built middle-aged man.

A 40 year old male patient presented with a history of chronic epigastric pain for four months; he had taken symptomatic treatment, but the pain was not relieved. USG abdomen and biochemical investigation were normal. Upper GI endoscopy was normal. There was no radiation of pain; the pain increased after 1-2 hours of food intake. Abdominal examination was normal. CECT whole abdomen showed moderate narrowing of proximal segment of celiac trunk by median arcuate ligament fibres with hooking and post stenotic dilatation; suggestive of median arcuate ligament syndrome (Figure 1). Laparoscopic division of the compressing fibres of the median arcuate ligament was done (Figure 2). The patient had an uneventful recovery postoperatively. He was pain-free at six months follow up.

Harjola first described median arcuate ligament syndrome (also known as Dunbar syndrome or celiac artery compression syndrome) in 1963.² Dunbar reported the first surgically treated patients.³ Patients are usually young, thin women between the ages of 30 and 50 and typically have had extensive workups for other sources of abdominal pain. The pathophysiology of the disease is external compression of the celiac artery by an abnormally low lying ligament. The compression worsens with expiration as the diaphragm moves caudally during expiration, causing compression of the celiac trunk. This compression leads to visceral ischemia and postprandial abdominal pain. Some also claim that this causes a “steal phenomenon,” where blood flow is diverted away from the superior mesenteric artery, via collaterals, to the celiac axis, causing midgut ischemia.⁴ A CT scan will be able to detect the focal narrowing of the celiac axis, particularly in sagittal views. This narrowing has a characteristic hooked appearance similar to that seen in our patient’s CT. Surgical treatment is the mainstay treatment of this syndrome. The patient gets relief of pain immediately, as happened in our case. 

We want to highlight this rare cause of epigastric pain. This possibility should be kept in a patient presenting with post-prandial epigastric abdominal pain of unknown aetiology. The CECT abdomen is diagnostic. Laparoscopic division of compressing fibres is the treatment of choice.