Presentation
Chronic epigastric pain for over five years, worsening after meals and in the supine position in a thin, otherwise healthy patient.
Patient Data
Non-atherosclerotic focal narrowing of the proximal coeliac axis at its origin with aliasing phenomenon indicating high jet due to external compression. Note the hook configuration of the vessel associated with accelerated velocities (peak-systolic 280 cm/s, end-diastolic 110 cm/s) in end-expiration which decrease to 180 cm/s and 75 cm/s respectively in deep inspiration. Flow is converted from turbulent to laminar and the vessel is straightened.
Additional finding: Prominent retroaortic left renal vein consistent with posterior nutcracker phenomenon.
Case Discussion
A case of median arcuate ligament syndrome in a thin middle aged woman with chronic post-prandial epigastric pain for over 5 years and normal overall test results including fibrogastroscopy.
Dunbar syndrome also known as Harjola-Marable syndrome refers to stenosis of the coeliac artery origin due to external compression by the diaphragmatic crura. Thin middle aged females are more commonly affected 1.
Imaging features include focal stenosis at the coeliac artery origin, post-stenotic dilatation/collaterals in the absence of atherosclerosis. Peak systolic velocity at the stenotic segment higher than 200 cm/s measured in mid-inspiration is highly suggestive of the diagnosis, followed by CT angiography or DSA as the gold standard imaging modalities 2.
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