Dunbar syndrome as a cause of chronic abdominal pain in a 24-year-old female

Abstract

External compression of the celiac artery by the median arcuate ligament is referred to as Dunbar syndrome, which is an eponym for celiac axis syndrome or median arcuate ligament syndrome. It is correlated with the archetypal triad of postprandial abdominal pain, weight loss of greater than 20 pounds, and an abdominal bruit on auscultation. This is often accompanied by epigastric tenderness, vomiting, and nausea. Given its lack of symptomatic specificity, Dunbar syndrome is a diagnosis of exclusion for unexplained episodic abdominal discomfort. Here, we present a unique case of a 24-year-old woman who experienced several months of chronic abdominal distress and an extensive workup prior to being diagnosed with Dunbar syndrome. The diagnosis was made via cross-sectional abdominal imaging and duplex ultrasound with respiratory maneuvers, which showed downward displacement of the celiac trunk, post-stenotic dilatation, and increased flow velocity on expiration. She underwent successful laparoscopic division of the median arcuate ligament which greatly alleviated her pain.

Keywords

Dunbar syndrome / Median arcuate ligament / Celiac trunk / Abdominal pain / Median arcuate ligament syndrome / Celiac artery compression syndrome

References

[1] Loukas M, Pinyard J, Vaid S, et al. Clinical anatomy of celiac artery compression syndrome: a review. Clin Anat. 2007 Aug; 20(6): 612-7. PMid:17309066. https://doi.org/10.1002/ca.2047

[2] Kim EN, Lamb K, Relles D, et al. Median Arcuate Ligament Syndrome-Review of This Rare Disease. JAMA Surg. 2016 01; 151(5): 471-7. PMid:26934394. https://doi.org/10.1001/jamasurg.2016.0002

[3] Saleem T, Baril DT. Celiac Artery Compression Syndrome. In: Stat- Pearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019. Available from: http://www.ncbi.nlm.nih.gov/books/NBK470601/

[4] Horton KM, Talamini MA, Fishman EK. Median arcuate ligament syndrome: evaluation with CT angiography. Radiographics. 2005 Oct; 25(5): 1177-82. PMid:16160104. https://doi.org/10.1148/rg.255055001

[5] Lindner HH. A Clinicoanatomical Study of the Arcuate Ligament of the Diaphragm. Arch Surg. 1971 Nov 1; 103( 5): 600. PMid:5117015. https://doi.org/10.1001/archsurg.1971.01350110102016

[6] van Petersen AS, Kolkman JJ, Gerrits DG, et al. Clinical significance of mesenteric arterial collateral circulation in patients with celiac artery compression syndrome. J Vasc Surg. 2017; 65(5): 1366-74. PMid:28259570. https://doi.org/10.1016/j.jvs.2016.11.052

[7] Dunbar JD, Molnar W, Beman FF, et al. Compression of the celiac trunk and abdominal angina. Am J Roentgenol Radium Ther Nucl Med. 1965 Nov; 95( 3): 731-44 PMid:5844938. https://doi.org/10.2214/ajr.95.3.731

[8] Williams S, Gillespie P, Little JM. Celiac axis compression syndrome: factors predicting a favorable outcome. Surgery. 1985 Nov; 98(5): 879-87. PMid:4060066. https://www.ncbi.nlm.nih.gov/pubmed/4060066

[9] Skeik N, Cooper LT, Duncan AA, et al. Median arcuate ligament syndrome: a nonvascular, vascular diagnosis. Vasc Endovascular Surg. 2011 Jul; 45(5): 433-7. PMid:21536596. https://doi.org/10.1177/1538574411406453

[10] Sultan S, Hynes N, Elsafty N, et al. Eight years experience in the management of median arcuate ligament syndrome by decompression, celiac ganglion sympathectomy, and selective revascularization. Vasc Endovascular Surg. 2013 Nov; 47(8): 614-9. PMid:23942948. https://doi.org/10.1177/1538574413500536

[11] Gruber H, Loizides A, Peer S, et al. Ultrasound of the median arcuate ligament syndrome: a new approach to diagnosis. Med Ultrason. 2012 Mar; 14(1): 5-9. PMid:22396932. https://www.ncbi.nlm.nih.gov/pubmed/22396932

[12] Duncan AA. Median arcuate ligament syndrome. Curr Treat Options Cardiovasc Med. 2008 Apr; 10(2): 112-6. PMid:18325313. https://www.ncbi.nlm.nih.gov/pubmed/18325313

[13] Reilly LM, Ammar AD, Stoney RJ, et al. Late results following operative repair for celiac artery compression syndrome. J Vasc Surg. 1985 Jan; 2(1): 79-91. PMid:3965762. https://www.ncbi.nlm.nih.gov/pubmed/3965762

[14] Jimenez JC, Harlander-Locke M, Dutson EP.Open and laparoscopic treatment of median arcuate ligament syndrome. J Vasc Surg. 2012 Sep; 56(3):869-73. PMid:22743019. https://doi.org/10.1016/j.jvs.2012.04.057