Letter to the Editor
Median arcuate ligament syndrome and upper gastrointestinal bleeding
Síndrome del ligamento arcuato mediano y hemorragia digestiva alta
a Departamento de Cirugía General, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
b Institute of Health Research of Navarra (IdisNA), Pamplona, Navarra, Spain
c CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Pamplona, Navarra, Spain
d Departamento de Cirugía, Hospital Universitario La Fe, Valencia, Spain
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Cienfuegos, Fernando Rotellar, Luis Hurtado-Pardo" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Javier A." "apellidos" => "Cienfuegos" "email" => array:1 [ 0 => "fjacien@unav.es" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Fernando" "apellidos" => "Rotellar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Luis" "apellidos" => "Hurtado-Pardo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Departamento de Cirugía General, Clínica Universidad de Navarra, Pamplona, Navarra, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Institute of Health Research of Navarra (IdisNA), Pamplona, Navarra, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Pamplona, Navarra, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Cirugía, Hospital Universitario La Fe, Valencia, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome del ligamento arcuato mediano y hemorragia digestiva alta" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cepeda González and Culebras Requena<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> describe a patient with median arcuate ligament syndrome (MALS) whose clinical presentation, in the form of gastrointestinal bleeding due to Forrest III gastric ulcer, associated with multiple ulcerated lesions and pangastritis (<span class="elsevierStyleItalic">H. pylori</span> negative), stands out.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In addition to the intense pain, which did not subside with opiates, the patient experienced gastrointestinal intolerance and weight loss (BMI 14.9<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>). CT angiography and selective arteriography detected severe celiac artery stenosis with poststenotic dilatation. After the surgical release of the median arcuate ligament (MAL), symptoms disappeared, the patient regained weight and the control endoscopy was normal.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Although the authors relate gastric lesions with a history <span class="elsevierStyleItalic">H. pylori infection</span>, we consider that gastric ischemia should not be ruled out in the pathogenesis of the case. Although the capacity of the stomach to develop collateral circulation from the pancreaticoduodenal arcade (arc of Buhler) is well known, hypoperfusion and mucosal ischemia have been described in MALS by gastric tonometry (difference of pCO<span class="elsevierStyleInf">2</span> luminal and arterial), as well as a recovery (normal values) after surgical release of MAL.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Other authors have described the “steal” phenomenon in physiological situations with greater oxygen demand: physical exercise, food intake.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Kalapatapu et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> have managed to reproduce MALS symptoms by selective vasodilation of the superior mesenteric artery in patients with celiac artery stenosis, confirming the association between symptoms and gastric ischemia.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The other relevant aspect is the excellent result obtained after the celiac artery is released. The patient had predictive signs of a good response to surgical treatment, such as severe stenosis >50–70% of the celiac artery and the presence of poststenotic dilatation.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Due to the lack of correlation between the radiological findings and the severity of the symptoms, the surgical decision can be complex, so these patients must be treated in multidisciplinary units: gastroenterologists, interventional radiologists, surgeons.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cienfuegos JA. Síndrome del ligamento arcuato mediano y hemorragia digestiva alta. Med Clin (Barc). 2020;155:89.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Medial arcuate ligament syndrome as an infrequent cause of refractory gastric ulcer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Cepeda González" 1 => "J. 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Vivas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s11605-017-3635-3" "Revista" => array:6 [ "tituloSerie" => "J Gastrointest Surg" "fecha" => "2018" "volumen" => "22" "paginaInicial" => "713" "paginaFinal" => "721" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29185149" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015500000002/v1_202007190713/S2387020620302564/v1_202007190713/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015500000002/v1_202007190713/S2387020620302564/v1_202007190713/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620302564?idApp=UINPBA00004N" ]
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