Dr Hsu’s theory is that this pain syndrome is a neurological issue, not a vascular issue. Therefore, he takes out the nerves in the affected area and the sensory portion of the celiac ganglion. He thinks the GI tract can get the necessary blood supply from the other two arteries leading to it. He is really the only person in the medical community and I know of who believes what he believes. Just because some people are without a celiac artery doesn’t mean everybody can live without it. In an open procedure which is required for me to have, the surgeon re-sects the median arcuate ligament and removes the celiac plexus nerves. Complete resection of the inflamed nerves has been shown to help reduce or completely eliminate the pain in over 90% of patients.Most doctors trim the nerves, and there are apparently nerves that need to be removed to access it. Some remove more nerves than others. Some also wait to see if the artery comes back to life.
Most doctors don’t know about this rare diagnosis, so MALS is under diagnosed pretty frequently. Differential diagnoses for epigastric pain include gastroparesis, eating disorders/anorexia, IBS, or gallbladder issues. Since MALS patients present with gastrointestinal symptoms, they often go through a battery of GI tests, including upper endoscopies, colonoscopies, EGDs, gastric emptying tests, and even nuclear medicine studies. Often, these tests sometimes show no abnormality, so most patients are referred for psychological evaluations or to eating disorder clinics because the doctors cannot find any physical evidence for the pain.
The anatomy for MALS can be seen on an abdominal CT scan with oral contrast. A mesenteric duplex can be used, although these are less specific tests compared to a color doppler US and visceral duplex scan. Other diagnostic criteria required for diagnosis include physical exam findings from a celiac ganglion block to rule in neurogenic cause of pain.
