A Median Arcuate Ligament Syndrome Could Be Re-termed as a Nutcracker Celiac Ganglion Abdominal Pain Syndrome

Ji Eun Kim; Mira Kang; Ok Soon Jeong; Poong-Lyul Rhee

doi:10.5056/jnm22158

J Neurogastroenterol Motil https://doi.org/10.5056/jnm22158

A Median Arcuate Ligament Syndrome Could Be Re-termed as a Nutcracker Celiac Ganglion Abdominal Pain Syndrome

Ji Eun Kim

,¹ Mira Kang,^2,3,4 Ok Soon Jeong,⁵ and Poong-Lyul Rhee

^1*

¹Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; ²Health Promotion Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; ³Digital Innovation Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; ⁴Department of Digital Health, SAIHST, Sungkyunkwan University School of Medicine, Seoul, Korea; and ⁵Department of Data service, Samsung Medical Center, Seoul, Korea

Correspondence to: *Poong-Lyul Rhee MD, PhD
Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
Tel: +82-2-3410-3409, Fax: +82-2-3410-6983, E-mail: plrhee@gmail.com
Ji Eun Kim and Mira Kang contributed equally to this work.

Received: September 10, 2022; Revised: November 24, 2022; Accepted: December 1, 2022; Published online: January 31, 2023

Abstract: Background/Aims
Median arcuate ligament syndrome (MALS) is known as chronic recurrent abdominal pain related to compression of the celiac artery by the median arcuate ligament. We aim to seek the specific mechanism of the pain by evaluating symptoms and radiological characteristics on abdominal CT scans.
Methods
We analyzed 35 patients who visited the emergency room for recurrent abdominal pain after cholecystectomy. We classified the characteristics of patients as 4 clinical components and 2 radiological components. We defined the sum of weighted clinical scores and weighted radiological scores as nutcracker ganglion abdominal pain syndrome (NCGAPS) scores. We categorized the patients into 3 groups classified by the degree of NCGAPS scores. The 3 patients with top-3 NCGAPS scores were recommended for CT angiography.
Results
When the suspicion was graded by NCGAPS scores, post stenotic dilatation was significantly different among all groups (P < 0.001). The clinical components of pain varied positional or respirational change and continuous pain were significantly different among all the groups (P < 0.01). NCGAPS scores can remarkably differentiate highly suspicious patients in comparison to simply combined scores. Only 1 patient in the highly suspicious group by NCGAPS scores took the CT angiography and was confirmed with NCGAPS.
Conclusions
We suggest renaming MALS as NCGAPS, nutcracker celiac ganglion abdominal pain syndrome, to better explain the mechanism of the recurrent abdominal pain. Further studies on the diagnostic cutoff of clinical and radiological scores of NCGAPS are needed not to miss the diagnosis of NCGAPS.; Keywords: Abdominal pain; Ganglia, sympathetic; Median arcuate ligament syndrome