Celiac artery compression: Dunbar syndrome

Síndrome da compressão da artéria celíaca (síndrome de Dunbar)

Giovanna Mezzalira Santos Luiz Marcelo Aiello Viarengo Marcos Danillo Peixoto Oliveira About the authors

Abstract

Celiac artery compression syndrome, also referred to as median arcuate ligament syndrome, celiac axis syndrome or Dunbar syndrome is a rare disorder consequent to extrinsic compression of the celiac trunk by the median arcuate ligament. Doppler ultrasound, multi-slice computed tomography angiography, magnetic resonance angiography, or invasive selective angiography can identify stenosis of the initial segment of the celiac artery and confirm diagnosis. Treatment options include open surgical or videolaparoscopic section of the median arcuate ligament and the fibers of the celiac plexus, or percutaneous transluminal angioplasty via an endovascular approach. We report herein an interesting case of a 38-year-old woman diagnosed with this rare condition and successfully treated with the surgical strategy.

Keywords:
Dunbar syndrome; celiac artery compression syndrome; median arcuate ligament syndrome

Resumo

A síndrome da compressão da artéria celíaca, também denominada síndrome do ligamento arqueado mediano, síndrome do eixo celíaco ou síndrome de Dunbar, é uma doença rara causada pela compressão extrínseca do tronco celíaco pelo ligamento arqueado mediano. Ultrassonografia Doppler, angiotomografia computadorizada, angiorressonância magnética ou angiografia seletiva invasiva conseguem identificar a estenose do segmento inicial da artéria celíaca e confirmar o diagnóstico. As opções de tratamento incluem secção videolaparoscópica ou laparotômica (a céu aberto) do ligamento arqueado mediano e das fibras do plexo celíaco, assim como angioplastia transluminal percutânea. Relatamos o interessante caso de uma mulher de 38 anos de idade diagnosticada com essa rara condição e adequadamente tratada pela estratégia cirúrgica.

Palavras-chave:
síndrome de Dunbar; síndrome da compressão da artéria celíaca; síndrome do ligamento arqueado mediano

INTRODUCTION

First described by Harjola11 Harjola PT. A rare obstruction of the coeliac artery: report of case. Ann Chir Gynaecol Fenn. 1963;52:547-50. PMid:14083857. in 1963 and Dunbar et al.22 Dunbar JD, Molnar W, Beman FF, Marable SA. Compression of celiac trunk and abdominal angina. Am J Roentgenol Radium Ther Nucl Med. 1965;95(3):731-44. http://dx.doi.org/10.2214/ajr.95.3.731. PMid:5844938.
http://dx.doi.org/10.2214/ajr.95.3.731...
in 1965, celiac artery compression syndrome (CACS), also referred to as median arcuate ligament syndrome (MALS), celiac axis syndrome (CAS), and Dunbar syndrome is a rare disorder consequent to extrinsic compression of the celiac trunk by the median arcuate ligament.33 Torres OJ, Gama-Filho OP, Torres CC, Medeiros RM, Oliveira CMB. Laparoscopic treatment of Dunbar syndrome: A case report. Int J Surg Case Rep. 2017;37:230-2. http://dx.doi.org/10.1016/j.ijscr.2017.06.056. PMid:28738298.
http://dx.doi.org/10.1016/j.ijscr.2017.0...

CACS is more prevalent in children and adolescents and is associated with specific symptoms, mainly during expiration. Symptoms include the classic triad of mesenteric ischemia: postprandial abdominal pain, nausea, and vomiting and subsequently weight loss.44 Gander S, Mulder DJ, Jones S, Ricketts JD, Soboleski DA, Justinich CJ. Recurrent abdominal pain and weight loss in an adolescent: celiac artery compression syndrome. Can J Gastroenterol. 2010;24(2):91-3. http://dx.doi.org/10.1155/2010/534654. PMid:20151065.
http://dx.doi.org/10.1155/2010/534654...
,55 Bobadilla JL. Mesenteric ischemia. Surg Clin North Am. 2013;93(4):925-40, ix. http://dx.doi.org/10.1016/j.suc.2013.04.002. PMid:23885938.
http://dx.doi.org/10.1016/j.suc.2013.04....
Pain is linked to compression of the celiac trunk (and probably also the celiac plexus) at the level of the diaphragm, due to insertion of the arcuate ligament at a lower level.33 Torres OJ, Gama-Filho OP, Torres CC, Medeiros RM, Oliveira CMB. Laparoscopic treatment of Dunbar syndrome: A case report. Int J Surg Case Rep. 2017;37:230-2. http://dx.doi.org/10.1016/j.ijscr.2017.06.056. PMid:28738298.
http://dx.doi.org/10.1016/j.ijscr.2017.0...

Once the syndrome is suspected, Doppler ultrasound (US), multi-slice computed tomography angiography (MSCTA), magnetic resonance angiography, or invasive selective angiography can identify stenosis of the initial segment of the celiac artery and confirm diagnosis. Treatment options include open surgical or videolaparoscopic section of the median arcuate ligament and the fibers of the celiac plexus, or percutaneous transluminal angioplasty via an endovascular approach.44 Gander S, Mulder DJ, Jones S, Ricketts JD, Soboleski DA, Justinich CJ. Recurrent abdominal pain and weight loss in an adolescent: celiac artery compression syndrome. Can J Gastroenterol. 2010;24(2):91-3. http://dx.doi.org/10.1155/2010/534654. PMid:20151065.
http://dx.doi.org/10.1155/2010/534654...
,55 Bobadilla JL. Mesenteric ischemia. Surg Clin North Am. 2013;93(4):925-40, ix. http://dx.doi.org/10.1016/j.suc.2013.04.002. PMid:23885938.
http://dx.doi.org/10.1016/j.suc.2013.04....

We report herein an interesting case of a 38-year-old woman diagnosed with this rare condition and successfully treated using the surgical strategy.

CASE DESCRIPTION

An active, Caucasian, otherwise healthy 38-year-old-woman was found to have a high mesogastric murmur, exacerbated during deep expiration. The remainder of her clinical examination was unremarkable, except for the presence of superficial varicose veins in her legs. Her complaints were post-prandial abdominal pain, dyspepsia, and post-exertional fatigue. Initial Doppler US (Figure 1) and subsequent MSCTA (Figure 2) suggested and confirmed, respectively, extrinsic celiac artery compression by the median arcuate ligament, compatible with CACS. In view of her symptoms, which were causing significant food intake restrictions and weight loss, surgical (laparotomic) treatment of the condition was proposed to the patient. The procedure was undertaken uneventfully and successfully, with section of the median arcuate ligament and the fibers of the celiac plexus. Three months later, the patient is totally free from any symptoms and a follow-up MSCTA (Figure 3) showed decompression of the celiac trunk.

Figure 1
US images showing end-expiratory (right panel) compression of the CT. Left panel, at rest; central panel, with deep inspiration; right panel, with deep expiration. CT = celiac trunk; SMA = superior mesenteric artery; EXP = expiration.
Figure 2
Multi-slice computed angiotomography with respiratory maneuvers - inspiration (left panels) and expiration (right panels). The typical hook-like downward stenosis of the celiac artery is due to the extrinsic compression by the arcuate ligament, especially at deep end expiration (right superior and inferior panels).
Figure 3
Postoperative multi-slice computed angiotomography with respiratory maneuvers - inspiration (left panels) and expiration (right panels) showing decompression of the celiac trunk.

DISCUSSION

CACS, MALS, CAS or Dunbar syndrome is a rare vascular compression syndrome, characterized by postprandial intestinal angina caused by impaired blood supply from the celiac artery to the gastrointestinal tract. The median arcuate ligament is located at the T12-L1 level and bridges the crura of the diaphragm, just anterior to the aorta. The celiac plexus is located between the arcuate ligament and the celiac trunk in up to 25% of normal individuals. Compression of the celiac trunk is, among other causes, secondary to diaphragm descensus after a period of accelerated growth in adolescents.33 Torres OJ, Gama-Filho OP, Torres CC, Medeiros RM, Oliveira CMB. Laparoscopic treatment of Dunbar syndrome: A case report. Int J Surg Case Rep. 2017;37:230-2. http://dx.doi.org/10.1016/j.ijscr.2017.06.056. PMid:28738298.
http://dx.doi.org/10.1016/j.ijscr.2017.0...

4 Gander S, Mulder DJ, Jones S, Ricketts JD, Soboleski DA, Justinich CJ. Recurrent abdominal pain and weight loss in an adolescent: celiac artery compression syndrome. Can J Gastroenterol. 2010;24(2):91-3. http://dx.doi.org/10.1155/2010/534654. PMid:20151065.
http://dx.doi.org/10.1155/2010/534654...
-55 Bobadilla JL. Mesenteric ischemia. Surg Clin North Am. 2013;93(4):925-40, ix. http://dx.doi.org/10.1016/j.suc.2013.04.002. PMid:23885938.
http://dx.doi.org/10.1016/j.suc.2013.04....

The condition has a 3:1 female to male ratio and the classic patient is a woman aged between 18 and 30 years.33 Torres OJ, Gama-Filho OP, Torres CC, Medeiros RM, Oliveira CMB. Laparoscopic treatment of Dunbar syndrome: A case report. Int J Surg Case Rep. 2017;37:230-2. http://dx.doi.org/10.1016/j.ijscr.2017.06.056. PMid:28738298.
http://dx.doi.org/10.1016/j.ijscr.2017.0...

4 Gander S, Mulder DJ, Jones S, Ricketts JD, Soboleski DA, Justinich CJ. Recurrent abdominal pain and weight loss in an adolescent: celiac artery compression syndrome. Can J Gastroenterol. 2010;24(2):91-3. http://dx.doi.org/10.1155/2010/534654. PMid:20151065.
http://dx.doi.org/10.1155/2010/534654...
-55 Bobadilla JL. Mesenteric ischemia. Surg Clin North Am. 2013;93(4):925-40, ix. http://dx.doi.org/10.1016/j.suc.2013.04.002. PMid:23885938.
http://dx.doi.org/10.1016/j.suc.2013.04....
Our patient was a 38 year-old woman and abdominal pain was her main symptom.

CACS is a rare entity, which is diagnosed in only 2 of 100,000 patients with ambiguous upper abdominal pain.66 Shetty R, Subramanyam K, Jacob CS. Dunbar syndrome: a rare presentation of abdominal angina treated by revascularization of the celiac artery by endovascular stenting. Int J Res Med Sci. 2018;6(6):2169-71. http://dx.doi.org/10.18203/2320-6012.ijrms20182308.
http://dx.doi.org/10.18203/2320-6012.ijr...
The incidence of this disease is not known and typical symptoms are chronic or recurring epigastric pain (especially post-prandial), nausea, vomiting, diarrhea, weight loss, epigastric bloating, and reduced appetite. Since these symptoms may be caused by other diseases, like esophagitis, pancreatitis, cholelithiasis, and food intolerance, CACS is a diagnosis of exclusion.33 Torres OJ, Gama-Filho OP, Torres CC, Medeiros RM, Oliveira CMB. Laparoscopic treatment of Dunbar syndrome: A case report. Int J Surg Case Rep. 2017;37:230-2. http://dx.doi.org/10.1016/j.ijscr.2017.06.056. PMid:28738298.
http://dx.doi.org/10.1016/j.ijscr.2017.0...

4 Gander S, Mulder DJ, Jones S, Ricketts JD, Soboleski DA, Justinich CJ. Recurrent abdominal pain and weight loss in an adolescent: celiac artery compression syndrome. Can J Gastroenterol. 2010;24(2):91-3. http://dx.doi.org/10.1155/2010/534654. PMid:20151065.
http://dx.doi.org/10.1155/2010/534654...
-55 Bobadilla JL. Mesenteric ischemia. Surg Clin North Am. 2013;93(4):925-40, ix. http://dx.doi.org/10.1016/j.suc.2013.04.002. PMid:23885938.
http://dx.doi.org/10.1016/j.suc.2013.04....

The classic manifestation of abdominal angina is seen in about 40% of patients. Two theories have been suggested to explain symptoms: compression of the mesenteric artery with mesenteric ischemia and splanchnic vasoconstriction due to stimulation of the celiac ganglion and celiac plexus.33 Torres OJ, Gama-Filho OP, Torres CC, Medeiros RM, Oliveira CMB. Laparoscopic treatment of Dunbar syndrome: A case report. Int J Surg Case Rep. 2017;37:230-2. http://dx.doi.org/10.1016/j.ijscr.2017.06.056. PMid:28738298.
http://dx.doi.org/10.1016/j.ijscr.2017.0...

4 Gander S, Mulder DJ, Jones S, Ricketts JD, Soboleski DA, Justinich CJ. Recurrent abdominal pain and weight loss in an adolescent: celiac artery compression syndrome. Can J Gastroenterol. 2010;24(2):91-3. http://dx.doi.org/10.1155/2010/534654. PMid:20151065.
http://dx.doi.org/10.1155/2010/534654...
-55 Bobadilla JL. Mesenteric ischemia. Surg Clin North Am. 2013;93(4):925-40, ix. http://dx.doi.org/10.1016/j.suc.2013.04.002. PMid:23885938.
http://dx.doi.org/10.1016/j.suc.2013.04....
Pain seems to be related to mechanical irritation of the celiac plexus nerve fibers. As in the present case, an epigastric bruit may be detected on clinical examination.

CACS can be investigated with Doppler US, MSCTA, magnetic resonance angiography, and selective invasive angiography. Doppler US has high sensitivity for diagnosis and has been proposed as the modality of choice, although the gold standard diagnostic method is still selective angiography, which should be performed during both inspiration and expiration. However, the introduction of MSCTA has enabled acquisition of thinner images, providing increased resolution, improved lesion detection, and excellent multiplanar reconstructions.77 França LH, Mottin C. Surgical treatment of Dunbar syndrome. J Vasc Bras. 2013;12(1):57-61. http://dx.doi.org/10.1590/S1677-54492013000100012.
http://dx.doi.org/10.1590/S1677-54492013...
Since stenosis is respiratory-dependent and becomes more obvious with deep expiration, respiratory maneuvers are needed for diagnosis. The classic hook-like downward displacement followed by a dilatation of the celiac artery is a typical finding.33 Torres OJ, Gama-Filho OP, Torres CC, Medeiros RM, Oliveira CMB. Laparoscopic treatment of Dunbar syndrome: A case report. Int J Surg Case Rep. 2017;37:230-2. http://dx.doi.org/10.1016/j.ijscr.2017.06.056. PMid:28738298.
http://dx.doi.org/10.1016/j.ijscr.2017.0...

4 Gander S, Mulder DJ, Jones S, Ricketts JD, Soboleski DA, Justinich CJ. Recurrent abdominal pain and weight loss in an adolescent: celiac artery compression syndrome. Can J Gastroenterol. 2010;24(2):91-3. http://dx.doi.org/10.1155/2010/534654. PMid:20151065.
http://dx.doi.org/10.1155/2010/534654...

5 Bobadilla JL. Mesenteric ischemia. Surg Clin North Am. 2013;93(4):925-40, ix. http://dx.doi.org/10.1016/j.suc.2013.04.002. PMid:23885938.
http://dx.doi.org/10.1016/j.suc.2013.04....

6 Shetty R, Subramanyam K, Jacob CS. Dunbar syndrome: a rare presentation of abdominal angina treated by revascularization of the celiac artery by endovascular stenting. Int J Res Med Sci. 2018;6(6):2169-71. http://dx.doi.org/10.18203/2320-6012.ijrms20182308.
http://dx.doi.org/10.18203/2320-6012.ijr...
-77 França LH, Mottin C. Surgical treatment of Dunbar syndrome. J Vasc Bras. 2013;12(1):57-61. http://dx.doi.org/10.1590/S1677-54492013000100012.
http://dx.doi.org/10.1590/S1677-54492013...
The present case was diagnosed using Doppler US and MSCTA.

Treatment modalities include endovascular (percutaneous transluminal angioplasty with stent implantation) and open (laparotomic) or videolaparoscopic surgical procedures.44 Gander S, Mulder DJ, Jones S, Ricketts JD, Soboleski DA, Justinich CJ. Recurrent abdominal pain and weight loss in an adolescent: celiac artery compression syndrome. Can J Gastroenterol. 2010;24(2):91-3. http://dx.doi.org/10.1155/2010/534654. PMid:20151065.
http://dx.doi.org/10.1155/2010/534654...
,55 Bobadilla JL. Mesenteric ischemia. Surg Clin North Am. 2013;93(4):925-40, ix. http://dx.doi.org/10.1016/j.suc.2013.04.002. PMid:23885938.
http://dx.doi.org/10.1016/j.suc.2013.04....
The first option does not always solve the problem of extrinsic compression and surgical intervention is sometimes needed.33 Torres OJ, Gama-Filho OP, Torres CC, Medeiros RM, Oliveira CMB. Laparoscopic treatment of Dunbar syndrome: A case report. Int J Surg Case Rep. 2017;37:230-2. http://dx.doi.org/10.1016/j.ijscr.2017.06.056. PMid:28738298.
http://dx.doi.org/10.1016/j.ijscr.2017.0...

4 Gander S, Mulder DJ, Jones S, Ricketts JD, Soboleski DA, Justinich CJ. Recurrent abdominal pain and weight loss in an adolescent: celiac artery compression syndrome. Can J Gastroenterol. 2010;24(2):91-3. http://dx.doi.org/10.1155/2010/534654. PMid:20151065.
http://dx.doi.org/10.1155/2010/534654...

5 Bobadilla JL. Mesenteric ischemia. Surg Clin North Am. 2013;93(4):925-40, ix. http://dx.doi.org/10.1016/j.suc.2013.04.002. PMid:23885938.
http://dx.doi.org/10.1016/j.suc.2013.04....

6 Shetty R, Subramanyam K, Jacob CS. Dunbar syndrome: a rare presentation of abdominal angina treated by revascularization of the celiac artery by endovascular stenting. Int J Res Med Sci. 2018;6(6):2169-71. http://dx.doi.org/10.18203/2320-6012.ijrms20182308.
http://dx.doi.org/10.18203/2320-6012.ijr...
-77 França LH, Mottin C. Surgical treatment of Dunbar syndrome. J Vasc Bras. 2013;12(1):57-61. http://dx.doi.org/10.1590/S1677-54492013000100012.
http://dx.doi.org/10.1590/S1677-54492013...
Symptomatic patients with confirmed CACS will benefit more from surgical treatments, based on direct visualization and division of the arcuate ligament to achieve decompression of the celiac artery. In some cases, reconstruction of the artery or interposition of a graft is necessary. Decompression by minimally invasive surgery should be the treatment of choice. Laparoscopic techniques and, more recently, robotically-assisted decompression have been reported as safe treatment modalities.33 Torres OJ, Gama-Filho OP, Torres CC, Medeiros RM, Oliveira CMB. Laparoscopic treatment of Dunbar syndrome: A case report. Int J Surg Case Rep. 2017;37:230-2. http://dx.doi.org/10.1016/j.ijscr.2017.06.056. PMid:28738298.
http://dx.doi.org/10.1016/j.ijscr.2017.0...

4 Gander S, Mulder DJ, Jones S, Ricketts JD, Soboleski DA, Justinich CJ. Recurrent abdominal pain and weight loss in an adolescent: celiac artery compression syndrome. Can J Gastroenterol. 2010;24(2):91-3. http://dx.doi.org/10.1155/2010/534654. PMid:20151065.
http://dx.doi.org/10.1155/2010/534654...

5 Bobadilla JL. Mesenteric ischemia. Surg Clin North Am. 2013;93(4):925-40, ix. http://dx.doi.org/10.1016/j.suc.2013.04.002. PMid:23885938.
http://dx.doi.org/10.1016/j.suc.2013.04....

6 Shetty R, Subramanyam K, Jacob CS. Dunbar syndrome: a rare presentation of abdominal angina treated by revascularization of the celiac artery by endovascular stenting. Int J Res Med Sci. 2018;6(6):2169-71. http://dx.doi.org/10.18203/2320-6012.ijrms20182308.
http://dx.doi.org/10.18203/2320-6012.ijr...
-77 França LH, Mottin C. Surgical treatment of Dunbar syndrome. J Vasc Bras. 2013;12(1):57-61. http://dx.doi.org/10.1590/S1677-54492013000100012.
http://dx.doi.org/10.1590/S1677-54492013...

In the present case, the choice of technique (open surgery) was based on the surgical team’s experience, whose previous cases treated by laparoscopy had not been fully decompressed, especially when there was a strong fibrotic band and the celiac ganglion was involved in the compression, as in this case. In our opinion, laparoscopic surgery is much more time-consuming and generally incomplete, most likely because of fear of accidentally causing an arterial injury.

In conclusion, CACS is a rare and uncommon cause of postprandial abdominal pain and should be kept in mind after eliminating all other commonly encountered causes. Open surgery is an effective and safe treatment option in selected symptomatic patients, with good long-term results.

  • How to cite: Santos GM, Viarengo LMA, Oliveira MDP. Celiac artery compression: Dunbar syndrome. J Vasc Bras. 2019;18:e20180094. https://doi.org/10.1590/1677-5449.009418
  • Financial support: None.
  • The study was carried out at Universidade de Taubaté (UNITAU), Taubaté, SP, Brazil.

REFERENCES

  • 1
    Harjola PT. A rare obstruction of the coeliac artery: report of case. Ann Chir Gynaecol Fenn. 1963;52:547-50. PMid:14083857.
  • 2
    Dunbar JD, Molnar W, Beman FF, Marable SA. Compression of celiac trunk and abdominal angina. Am J Roentgenol Radium Ther Nucl Med. 1965;95(3):731-44. http://dx.doi.org/10.2214/ajr.95.3.731 PMid:5844938.
    » http://dx.doi.org/10.2214/ajr.95.3.731
  • 3
    Torres OJ, Gama-Filho OP, Torres CC, Medeiros RM, Oliveira CMB. Laparoscopic treatment of Dunbar syndrome: A case report. Int J Surg Case Rep. 2017;37:230-2. http://dx.doi.org/10.1016/j.ijscr.2017.06.056 PMid:28738298.
    » http://dx.doi.org/10.1016/j.ijscr.2017.06.056
  • 4
    Gander S, Mulder DJ, Jones S, Ricketts JD, Soboleski DA, Justinich CJ. Recurrent abdominal pain and weight loss in an adolescent: celiac artery compression syndrome. Can J Gastroenterol. 2010;24(2):91-3. http://dx.doi.org/10.1155/2010/534654 PMid:20151065.
    » http://dx.doi.org/10.1155/2010/534654
  • 5
    Bobadilla JL. Mesenteric ischemia. Surg Clin North Am. 2013;93(4):925-40, ix. http://dx.doi.org/10.1016/j.suc.2013.04.002 PMid:23885938.
    » http://dx.doi.org/10.1016/j.suc.2013.04.002
  • 6
    Shetty R, Subramanyam K, Jacob CS. Dunbar syndrome: a rare presentation of abdominal angina treated by revascularization of the celiac artery by endovascular stenting. Int J Res Med Sci. 2018;6(6):2169-71. http://dx.doi.org/10.18203/2320-6012.ijrms20182308
    » http://dx.doi.org/10.18203/2320-6012.ijrms20182308
  • 7
    França LH, Mottin C. Surgical treatment of Dunbar syndrome. J Vasc Bras. 2013;12(1):57-61. http://dx.doi.org/10.1590/S1677-54492013000100012
    » http://dx.doi.org/10.1590/S1677-54492013000100012

Publication Dates

  • Publication in this collection
    30 May 2019
  • Date of issue
    2019

History

  • Received
    07 Oct 2018
  • Accepted
    06 Dec 2018
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