MALS, which stands for Median Arcuate Ligament Syndrome, is a congenital anatomical anomaly. It is caused by the median arcuate ligament compressing the celiac artery and the celiac ganglion, which can cause a change in blood flow and/or epigastric pain. It is found in 15%-34% of the US population, but only one percent of that number experience symptoms.
MALS was first described as a medical condition by Dr. Harjola in 1963. Over the years, it has been known by other names, including Dunbar Syndrome and Celiac Artery Compression Syndrome. It has recently been listed on the Rare Disease Registry, and between 1963 and 2012, less than 500 corrective MALS surgeries were recorded in the English language. However, based on the current percentage estimates and the 2016 US population numbers, the statistical number of people with the MALS anatomy is 48.5 million to 11 million. Of those, half a million to 1.1 million will experience symptoms.
In a MALS patient, the diaphragm is located too low within his or her body, which lowers the median arcuate ligament. In a non-MALS patient, the ligament is located approximately four centimeters above the celiac artery. In a MALS patient, the ligament compresses the celiac artery and the celiac ganglion (a bundle of sympathetic nerves between the artery and ligament). This compression is present at the time of a patient’s birth, but symptoms often don’t develop until adolescence.
MALS symptoms are most common among young women. The symptoms of MALS mimic gastrointestinal issues and may include upper-abdominal pain after eating, fatigue after eating, nausea and/or vomiting, constipation or diarrhea, exercise intolerance, and rapid weight loss. Unlike most gastrointestinal illnesses, MALS will not show up in blood work or in typical GI testing. Patients are often misdiagnosed with gallbladder issues, chronic abdominal pain, gastroparesis, eating disorders/food avoidance, and a myriad of other non-specific diagnoses. Patients may be given pain medications in an attempt to lessen their symptoms, and while this may work for a time, it does not solve the root problem.
MALS can only be treated with surgical intervention. However, there are currently only a few surgeons in the US who have experience in treating MALS, and procedures vary between each surgeon. Some surgeons use a laparoscopic approach to release the ligament, while others perform an open surgery and entirely remove the ligament and celiac ganglion. It is important for patients and caretakers to thoroughly research treatment options to find the best surgeon and treatment plan for them.