Median arcuate ligament syndrome presenting as

American Journal of Emergency Medicine 31 (2013) 1152.e1–1152.e4

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Case Report

Median arcuate ligament syndrome presenting as hemorrhagic shock Abstract

The major symptoms of median arcuate ligament syndrome, celiac axis stenosis, or occlusion compressed by the median arcuate ligament include eating-associated abdominal pain and weight loss. Because celiac stenosis increases retrograde collateral blood flow from the superior mesenteric artery to the celiac artery via the pancreaticoduodenal arcade, a pancreaticoduodenal artery aneurysm could occur at a low incidence rate. Rupture of the pancreaticoduodenal artery aneurysm and hemorrhagic shock are rare. In this report, we present 3 cases of patients who had been well with no abdominal symptoms until the day of admission, when they experienced sudden-onset intra-abdominal hemorrhage and shock. These 3 patients were admitted to the emergency department, and contrast-enhanced computed tomography and radiographic selective catheter angiography revealed intra-abdominal hemorrhage, stenosis of the celiac arteries, and dilated pancreaticoduodenal arcade. Case 1 demonstrated severe hemorrhagic shock, whereas case 2 demonstrated moderate shock. We treated ruptured pancreaticoduodenal artery aneurysms with coil embolization. Case 3 demonstrated complete celiac occlusion and moderate hemorrhagic shock, and no aneurysm was detected. Median arcuate ligament syndrome, celiac axis stenosis, or occlusion compressed by the median arcuate ligament rarely cause upper abdominal pain [1,2]. The celiac stenosis increases retrograde collateral blood flow from the superior mesenteric artery (SMA) to the celiac artery perfusion area via pancreaticoduodenal arcade and could form pancreaticoduodenal artery aneurysms. We describe 3 patients who presented to the emergency department of the hospital with sudden-onset intra-abdominal hemorrhage and shock. A 69-year-old woman was transferred to the emergency department of the hospital because of sudden collapse and hypotension. She had a history of atrial fibrillation and was currently taking warfarin. She was healthy and without any abdominal symptoms or trauma history until the day of admission. Upon admission, her blood pressure was 52/immeasurable mm Hg; pulse rate, 130 beats/min; respiratory rate, 36 breaths/min; hemoglobin level, 5.2 g/dL; and hematocrit, 15.9%. Abdominal contrast-enhanced computed tomography (CT) revealed a massive retroperitoneal hematoma around the head of the pancreas with active arterial extravasation and focal narrowing of the celiac axis (Fig. 1 and 2). Radiographic selective catheter angiography of the SMA revealed retrograde blood flow from the SMA to the celiac artery via the pancreaticoduodenal arcade and extravasations from the inferior pancreaticoduodenal artery and posterior superior pancreaticoduodenal artery (Fig. 3). The extravasations were effectively treated with transcatheter arterial embolization (TAE) using platinum coils. 0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved.

Fig. 1. Massive hematoma with arterial extravasation shown on contrast-enhanced CT.

Fig. 2. Celiac axis stenosis shown on 3-dimensional CT angiography.