Jeffrey N Harr1, Ivy N Haskins1, Fred Brody2. 1. Department of Surgery, The George Washington University Medical Center, The George Washington University, 2150 Pennsylvania Ave, NW Suite 6B, Washington, DC, 20037, USA. 2. Department of Surgery, The George Washington University Medical Center, The George Washington University, 2150 Pennsylvania Ave, NW Suite 6B, Washington, DC, 20037, USA. fbrody@mfa.gwu.edu.
Abstract
BACKGROUND: Exercise-related transient abdominal pain (ETAP) is a common entity in young athletes. Most occurrences are due to a "cramp" or "stitch," but an uncommon, and often overlooked, etiology of ETAP is median arcuate ligament syndrome (MALS). The initial presentation of MALS typically includes postprandial nausea, bloating, abdominal pain, and diarrhea, but in athletes, the initial presentation may be ETAP. METHODS: We present a case series of three athletes who presented with exercise-related transient abdominal pain and were ultimately diagnosed and treated for MALS. Unlike other patients with median arcuate ligament syndrome, these athletes presented with exercise-induced pain, rather than the common postprandial symptoms. These symptoms persisted despite conservative measures. Work-up of patients with suspected MALS include a computed tomography or magnetic resonance angiography showing compression of the celiac artery with post-stenotic dilation, or a celiac artery ultrasound demonstrating increased velocities (>200 cm/s2) with deep exhalation. RESULTS: All patients underwent a laparoscopic median arcuate ligament release. Postoperatively, there were no complications, and all were discharged home on postoperative day #2. All patients have subsequently returned to athletics with resolution of their symptoms. CONCLUSION: ETAP is common in athletes and often resolves with preventative or conservative strategies. When ETAP persists despite these methods, alternative causes, including MALS, should be considered. A combination of a thorough history and physical exam, as well as radiographic data, is essential to make the appropriate diagnosis and treatment strategy.
BACKGROUND: Exercise-related transient abdominal pain (ETAP) is a common entity in young athletes. Most occurrences are due to a "cramp" or "stitch," but an uncommon, and often overlooked, etiology of ETAP is median arcuate ligament syndrome (MALS). The initial presentation of MALS typically includes postprandial nausea, bloating, abdominal pain, and diarrhea, but in athletes, the initial presentation may be ETAP. METHODS: We present a case series of three athletes who presented with exercise-related transient abdominal pain and were ultimately diagnosed and treated for MALS. Unlike other patients with median arcuate ligament syndrome, these athletes presented with exercise-induced pain, rather than the common postprandial symptoms. These symptoms persisted despite conservative measures. Work-up of patients with suspected MALS include a computed tomography or magnetic resonance angiography showing compression of the celiac artery with post-stenotic dilation, or a celiac artery ultrasound demonstrating increased velocities (>200 cm/s2) with deep exhalation. RESULTS: All patients underwent a laparoscopic median arcuate ligament release. Postoperatively, there were no complications, and all were discharged home on postoperative day #2. All patients have subsequently returned to athletics with resolution of their symptoms. CONCLUSION: ETAP is common in athletes and often resolves with preventative or conservative strategies. When ETAP persists despite these methods, alternative causes, including MALS, should be considered. A combination of a thorough history and physical exam, as well as radiographic data, is essential to make the appropriate diagnosis and treatment strategy.
Authors: Julio Cezar Uili Coelho; Andréa Virmond El Hosni; Christiano MarloPaggi Claus; Yan Sacha Hass Aguilera; Gisele Pitrowsk Abot; Alexandre Teixeira Coutinho de Freitas; Marco Aurélio Raeder da Costa Journal: Arq Bras Cir Dig Date: 2020-05-18