{"id":36950,"date":"2020-12-30T15:37:43","date_gmt":"2020-12-30T22:37:43","guid":{"rendered":"https:\/\/www.uchealth.org\/today\/?p=36950"},"modified":"2023-01-23T09:56:10","modified_gmt":"2023-01-23T16:56:10","slug":"solving-the-pain-nausea-caused-by-median-arcuate-ligament-syndrome","status":"publish","type":"post","link":"https:\/\/www.uchealth.org\/today\/solving-the-pain-nausea-caused-by-median-arcuate-ligament-syndrome\/","title":{"rendered":"Teamwork frees patient from severe pain, nausea caused by median arcuate ligament syndrome"},"content":{"rendered":"
<\/div>
\"With
With her median arcuate ligament syndrome successfully treated, Anna went out for and made the CU Boulder Climbing Team. Here she practices at G1 Climbing and Fitness in Broomfield. Photo courtesy of Anna Bajaj.<\/figcaption><\/figure>\n

This past September, Anna Bajaj received the welcome news that she\u2019d successfully scaled a challenge she set for herself. The 19-year-old from Highlands Ranch learned that she\u2019d made the Climbing Team at the University of Colorado Boulder<\/a>, where she is a freshman.<\/p>\n

On the surface, the selection might not be a surprise. Bajaj taught rock climbing in high school and searches for hand- and footholds on vertical walls several times a week. But about a year ago, she faced a challenge to pursuing that passion. For many months, the obstacle appeared as unyielding as an expanse of rock.<\/p>\n

Bajaj suffered from<\/a> median arcuate ligament syndrome (MALS), a condition that affects only about 2 in 100,000 people<\/a>. The median arcuate ligament is a band of fibrous tissue that attaches the diaphragm to the spine. To make that connection, it loops around the aorta, the main artery carrying blood from the heart to the body. Branching off the aorta are vessels that supply critical blood flow throughout the body. One of them is the celiac artery, which supplies blood to the stomach, liver, spleen and other organs. This artery is the focus of the MALS problem.<\/p>\n

A troublesome tightening in her median arcuate ligament<\/strong><\/h3>\n

In people with MALS, the median arcuate ligament compresses the celiac artery, causing severe pain, nausea and other symptoms, particularly after eating. For Anna Bajaj, the first signs of what turned out to be median arcuate ligament syndrome began around Thanksgiving with an unexplained lack of appetite. But by the beginning of 2020, she suffered from pain she described as a \u201cheavy, burning rock\u201d between her breastbone and navel. Minutes after eating, she felt like throwing up. Meals became hurried one-time-a-day endurance tests.<\/p>\n

After months of pain and suffering that sidelined her from rock climbing and horseback riding \u2013 another serious pursuit \u2013 and made her senior year of high school a struggle, Bajaj finally found a diagnosis and resolution for her median arcuate ligament syndrome at UCHealth University of Colorado Hospital<\/a> on the Anschutz Medical Campus<\/a>. She benefited from surgical teamwork that is unique in the state of Colorado.<\/p>\n

\"Anna
Anna takes on a rock face, this one at Devil\u2019s Head, southwest of Denver. Photo courtesy of Anna Bajaj.<\/figcaption><\/figure>\n

Teamwork at the table to rectify median arcuate ligament syndrome<\/strong><\/h3>\n

The MALS diagnosis led Bajaj to a surgical suite at UCH last May. There, Dr. Akshay Chauhan<\/a>, assistant professor of GI, Endocrine and Tumor Surgery<\/a> at the University of Colorado School of Medicine<\/a>, worked laparoscopically, making tiny incisions in her abdomen and inserting tools he would use to painstakingly cut enough of the median arcuate ligament to ease its compression of the celiac artery and a bundle of nerves called the celiac plexus.<\/p>\n

\"Akshay
Dr. Akshay Chauhan performed the robotic surgery that eliminated the symptoms of Anna\u2019s median arcuate ligament syndrome. Photo by UCHealth.<\/figcaption><\/figure>\n

Akshay performed the surgery with a robotic assistant. He sat at a console several feet from the operating table, manipulating his surgical tools with a robotic arm that functioned in place of his own. At a second console, he had another collaborator: CU vascular surgeon Dr. Jeniann Yi<\/a>, who followed and supported Chauhan\u2019s procedure. Yi had two vital roles. If inadvertent damage to an artery occurred, she was ready to immediately perform an open surgery to make repairs. She also advised Chauhan about how much of the ligament to cut safely to relieve the compression while protecting the celiac artery.<\/p>\n

\u201cAs vascular surgeons, our expertise is to say, \u2018You\u2019re safe to keep dissecting in this area, and you need to because you\u2019re not quite to the arterial wall yet,\u201d Yi said. \u201cThere is still more tissue you need to get through until the artery is totally free.\u201d<\/p>\n

Surgical evolution for MALS\u00a0<\/strong><\/h3>\n

Chauhan said open MALS surgeries began about three decades ago. Laparoscopic surgery followed, reducing recovery times and post-operative pain. Robotic surgery \u201cchanged the paradigm,\u201d he said, by improving surgeons\u2019 control over the instruments and providing 3D imaging and vastly improved magnification \u2013 up to 30 times greater than microscopic glasses worn by Yi compared the difference to viewing an image in 4K instead of analog.<\/p>\n

\"Vascular
Vascular surgeon Dr. Jeniann Yi collaborated with Dr. Chauhan to ensure a safe and ideal outcome for Anna\u2019s median arcuate ligament syndrome surgery. Photo by UCHealth.<\/figcaption><\/figure>\n

Having a robotic-trained general surgeon work side by side with a vascular surgeon, as now happens at UCH \u2013 the only place where it occurs in Colorado \u2013 is \u201cthe next evolution\u201d in improving patient safety and outcomes, Chauhan said.<\/p>\n

\u201cI believe in collaboration,\u201d he said. \u201cPutting two minds into a complex patient problem improves outcomes.\u201d<\/p>\n

\u201cWe help each other out because we\u2019re combining our knowledge bases to help patients,\u201d Yi added.<\/p>\n

MALS: A mysterious malady<\/strong><\/h3>\n

Anna Bajaj benefited from the work of Chauhan and Yi, but she had a long, frustrating journey to the operating table. That\u2019s not unusual, said Dr. Max Wohlauer<\/a>, a vascular surgery colleague of Yi who also works with Chauhan.<\/p>\n

Wohlauer noted that the stomach pain and nausea that are symptoms of median arcuate ligament syndrome mimic other digestive problems and may sometimes be dismissed as psychological issues. On top of being exceedingly rare, MALS requires an extensive workup to diagnose. Providers may be baffled even after extensive investigation.<\/p>\n

Bajaj went through around a dozen inconclusive tests over several months before Yi confirmed the diagnosis with an ultrasound scan that shows increased blood flow velocity through the celiac artery, a sign that the vessel is compressed.<\/p>\n

\u201cThe pain makes people miserable and it takes a while to come to the diagnosis,\u201d Wohlauer said. \u201cWhen they end up in our clinic, they\u2019ve often come to the end of their rope. They\u2019ve tried everything and still feel miserable.\u201d<\/p>\n

\"Median
Median arcuate ligament syndrome surgery helped to restore Anna\u2019s time with her horses. Photo courtesy of Anna Bajaj.<\/figcaption><\/figure>\n

Symptoms of median arcuate ligament syndrome<\/strong><\/h3>\n

That description could apply to Anna Bajaj. Prior to the Thanksgiving warning signs that harbingered median arcuate ligament syndrome in 2019, Bajaj described herself as \u201ca super-active young woman\u201d and straight-A student at Heritage High School in Littleton. Her days began early with devotion and Bible study. During her senior year, she took advanced classes in English, anatomy, physiology, and medical ethics at Arapahoe Community College.<\/p>\n

The busy schedule, she said, \u201creflected my heart, my personality and the energy I had. It was all go, go, go, never slowing down.\u201d<\/p>\n

During that Thanksgiving weekend, Bajaj said, she noticed she lacked her normally healthy appetite. She didn\u2019t think much of it initially, but the feeling persisted over the following month and then got worse. She began eating less frequently and by Christmas was down to one meal a day. After eating she felt nauseous, and then came the feelings of a stone in her stomach, first one large and warm, later heavy and burning. Meals brought sharp pain on both sides of her abdomen within minutes.<\/p>\n

Each day brought a dilemma. Bajaj was so hungry because of the single daily meal regimen that she couldn\u2019t wait to eat. But anxiety laced every food encounter because of the pain she knew was coming. Drinking was as difficult as eating, so she became dehydrated. Her physical reserves faded. Her exhaustion sidelined her from rock climbing and horseback riding.<\/p>\n

\"Anna
Anna Bajaj has returned to horseback riding in shows since her surgery to treat MALS. She\u2019s shown here at the Douglas County Fairgrounds. Photo courtesy of Anna Bajaj.<\/figcaption><\/figure>\n

Struggle to maintain the life caused by MALS<\/strong><\/h3>\n

The daily attacks brought another challenge. Beginning in the fall of 2018 Bajaj had begun battling another condition called functional neurological disorder<\/a> that periodically caused relatively brief bouts of paralysis. She had begun learning to manage the problem, but with the onset of her eating problems, the periods of paralysis returned more frequently.<\/p>\n

Meanwhile, she labored to finish her senior year in high school. She had to hold the line against two difficult physical problems without sacrificing the high scholastic standards she set for herself.<\/p>\n

With the help of understanding teachers and her enduring faith, she met her academic goals. \u201cTrying to finish strong my senior year was the toughest thing I\u2019ve had to do in my life so far,\u201d Bajaj said.<\/p>\n

Median arcuate ligament syndrome: A hard diagnosis<\/strong><\/h3>\n

Bajaj was hardly a passive victim of the mysterious malady she ultimately learned was median arcuate ligament syndrome. She had her gallbladder tested before getting a referral to a gastroenterology practice in Littleton. A battery of tests and scans of her upper GI, abdomen, liver and pancreas followed, without identifying a cause or solution. During this period, from January to early March, the pain and nausea worsened.<\/p>\n

Desperate for an answer, but getting none, Bajaj finally found Yi at the UCHealth Heart and Vascular Clinic<\/a>. She calls that a \u201cbig turning point in my confidence. I felt like [Dr. Yi] really cared about me and my case and saw it as serious as I felt it was,\u201d Bajaj said.<\/p>\n

Yi\u2019s examination, which included the ultrasound velocity test, confirmed median arcuate ligament syndrome. She laid out Bajaj\u2019s options, one of which was Chauhan\u2019s compression release surgery. The prospect of major surgery was daunting, Bajaj said, but she trusted Yi and Chauhan, particularly when she learned he had extensive experience with the MALS procedure.<\/p>\n

That confidence was to grow. The day of the surgery, Chauhan prepared Bajaj with a diagram of what he would do to fix the problem that had vexed her for months.<\/p>\n

\u201cHe explained things to me like I was one of his students,\u201d she said. \u201cHe was so kind, compassionate and knowledgeable.\u201d<\/p>\n

Pain-free at last after median arcuate ligament syndrome procedure<\/strong><\/h3>\n

After she awoke from surgery, she saw Chauhan again. He had reassuring words for her. \u201cHe told me, \u2018You will feel better and will not have this pain anymore,\u2019\u201d Bajaj remembered.<\/p>\n

He was right. After six months of fractured eating patterns, Bajaj says she ordered and ate two pieces of pie, a slice of cake, macaroni and cheese, Ramen noodles and Cheerios. She was stuffed, but that was the only pain she felt.<\/p>\n

\u201cIf I wasn\u2019t in pain from the surgery, I\u2019d have jumped for joy,\u201d Bajaj said.<\/p>\n

\"Anna\u2019s
Anna\u2019s time with her horses has been restored thanks to her surgery. Photo courtesy of Anna Bajaj.<\/figcaption><\/figure>\n

Leaving MALS behind<\/strong><\/h3>\n

She spent the summer resting, recuperating and fine-tuning her eating habits. With the help of her mom, Lyn, she set her schedule to ensure that she ate at least a bite or two every three hours and made sure she balanced her diet with fruits and vegetables. The pain from median arcuate ligament syndrome, blessedly, is completely gone.<\/p>\n

In addition to making the Climbing Team at CU, Bajaj is back on the equine circuit, taking part in horse shows a couple of times a month. Her care from Chauhan and YI also yielded an unexpected side benefit: a connection with Dr. Samantha Holden<\/a>, assistant professor in the Department of Neurology<\/a> at CU, who has helped her better manage her functional neurological disorder.<\/p>\n

For her part, Yi believes Bajaj contributed to her own success in surmounting the walls that MALS unexpectedly mounted before her.<\/p>\n

\u201cAnna was a great advocate for herself and deserves credit for being able to push her own care forward,\u201d Yi said.<\/p>\n","protected":false},"excerpt":{"rendered":"

This past September, Anna Bajaj received the welcome news that she\u2019d successfully scaled a challenge she set for herself. The 19-year-old from Highlands Ranch learned that she\u2019d made the Climbing Team at the University of Colorado Boulder, where she is a freshman. On the surface, the selection might not be a surprise. Bajaj taught rock […]<\/p>\n","protected":false},"author":2143,"featured_media":36959,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":"","footnotes":""},"categories":[5],"tags":[743,3512,702],"class_list":["post-36950","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-innovative-care","tag-digestive-health-liver-and-pancreas-gastroenterology","tag-heart-and-vascular-care-cardiovascular","tag-surgical-care"],"acf":[],"yoast_head":"\nSolving pain, nausea caused by median arcuate ligament syndrome - 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