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nailed it
abd pain for 1 year. ordered by IM to rule out MALS. make me love medinine again for a brief moment.[:D]
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12 Replies
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How many people have this asymptomatically or incidentally? I see this appearance very frequently when I start looking at sagittal recons.
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Quote from dr77767
How many people have this asymptomatically or incidentally? I see this appearance very frequently when I start looking at sagittal recons.
Yeah I called this once, textbook picture like that and maybe elevated lactate or something as well. ED doc thought I was nuts. Pt was in for a bellyache after smoking too much weed.-
Nice diagnosis!
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MALS is a controversial dx.
-Arcuate ligament effacement of the celiac can be seen normally.
-Technically need inspiration and expiration imaging.
-Doppler is the common first step, with insp/exp. Doppler velocities are high normally in adolescents and children, way above the adult 200 cm/sec, so be careful.
-The pain is attributed to compression of the celiac plexus adjacent to the artery, not ischemia; so lactate would not be elevated. Besides with a patent SMA, ischemia would be highly unlikely even with a fixed stenosis.
-When we did runoffs, compression of the celiac was commonly seen incidentally, and ignored. Maybe some of them had MALS, but most not.
Anyway, not a slam dunk, especially depending on the compression of the celiac.-
I used to call it a lot and frequently put it in the impression. May me feel special. Didnt make a difference to the patient. Now, I sometimes call it if there isnt much else going on. SMA syndrome is another one that can look classic on imaging, but have no clinical significance to the patient.
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I feel like I see this on about 1 of every 10 cases so I stopped mentioning it.
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You guys are seeing cases that look like this one, with that deep incisural extrinsic compression?! I see ligament compression of some degree all the time, but this one has the hallmarks of clinical disease to me eye. As much as one can say based on one image anyway.
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Ya. Surgeon must have kids going to college soon! Maybe the IR guy can get a piece by diagnosing in the fluro room too!
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I vote:
— worth mentioning
— less than 50% chance this is causing the patient’s symptoms
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exam ordered to rule out MALS and you saw this. you do not want to mention it. Your impression will be no evidence of MALS. Are you sure? I did not show the axial. On axial there is 90% stenosis.
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Cant say Ive ever had an exam indication say rule out MALS.
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I would mention it because likely they have already done extensive testing to exclude more common causes of abdominal pain.
The probability of this finding being clinically significant is therefore higher.
It’s similar to Nutcracker syndrome where we see very commonly see a compressed L renal vein. The main time to mention it is if they are asking for it, as presumably there are clinical findings fitting it.
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