Teamwork frees patient from severe pain, nausea caused by median arcuate ligament syndrome

With the help of surgical teamwork that is unique in Colorado, Anna Bajaj recovered from a rare condition called median arcuate ligament syndrome that unexpectedly disrupted her life.
Dec. 30, 2020
With her MALS successfully treated, Anna went out for and made the CU Boulder Climbing Team. Here she practices at G1 Climbing and Fitness in Broomfield. Photo courtesy of Anna Bajaj.
With her median arcuate ligament syndrome successfully treated, Anna went out for and made the CU Boulder Climbing Team. Here she practices at G1 Climbing and Fitness in Broomfield. Photo courtesy of Anna Bajaj.

This past September, Anna Bajaj received the welcome news that she’d successfully scaled a challenge she set for herself. The 19-year-old from Highlands Ranch learned that she’d made the Climbing Team at the University of Colorado Boulder, where she is a freshman.

On the surface, the selection might not be a surprise. Bajaj taught rock climbing in high school and searches for hand- and footholds on vertical walls several times a week. But about a year ago, she faced a challenge to pursuing that passion. For many months, the obstacle appeared as unyielding as an expanse of rock.

Bajaj suffered from median arcuate ligament syndrome (MALS), a condition that affects only about 2 in 100,000 people. The median arcuate ligament is a band of fibrous tissue that attaches the diaphragm to the spine. To make that connection, it loops around the aorta, the main artery carrying blood from the heart to the body. Branching off the aorta are vessels that supply critical blood flow throughout the body. One of them is the celiac artery, which supplies blood to the stomach, liver, spleen and other organs. This artery is the focus of the MALS problem.

A troublesome tightening in her median arcuate ligament

In people with MALS, the median arcuate ligament compresses the celiac artery, causing severe pain, nausea and other symptoms, particularly after eating. For Anna Bajaj, the first signs of what turned out to be median arcuate ligament syndrome began around Thanksgiving with an unexplained lack of appetite. But by the beginning of 2020, she suffered from pain she described as a “heavy, burning rock” between her breastbone and navel. Minutes after eating, she felt like throwing up. Meals became hurried one-time-a-day endurance tests.

After months of pain and suffering that sidelined her from rock climbing and horseback riding – another serious pursuit – and made her senior year of high school a struggle, Bajaj finally found a diagnosis and resolution for her median arcuate ligament syndrome at UCHealth University of Colorado Hospital on the Anschutz Medical Campus. She benefited from surgical teamwork that is unique in the state of Colorado.

Anna takes on a rock face, this one at Devil’s Head, southwest of Denver. Photo courtesy of Anna Bajaj.
Anna takes on a rock face, this one at Devil’s Head, southwest of Denver. Photo courtesy of Anna Bajaj.

Teamwork at the table to rectify median arcuate ligament syndrome

The MALS diagnosis led Bajaj to a surgical suite at UCH last May. There, Dr. Akshay Chauhan, assistant professor of GI, Endocrine and Tumor Surgery at the University of Colorado School of Medicine, worked laparoscopically, making tiny incisions in her abdomen and inserting tools he would use to painstakingly cut enough of the median arcuate ligament to ease its compression of the celiac artery and a bundle of nerves called the celiac plexus.

Akshay Chauhan performed the robotic surgery that eliminated the symptoms of Anna’s median arcuate ligament syndrome.
Dr. Akshay Chauhan performed the robotic surgery that eliminated the symptoms of Anna’s median arcuate ligament syndrome. Photo by UCHealth.

Akshay performed the surgery with a robotic assistant. He sat at a console several feet from the operating table, manipulating his surgical tools with a robotic arm that functioned in place of his own. At a second console, he had another collaborator: CU vascular surgeon Dr. Jeniann Yi, who followed and supported Chauhan’s procedure. Yi had two vital roles. If inadvertent damage to an artery occurred, she was ready to immediately perform an open surgery to make repairs. She also advised Chauhan about how much of the ligament to cut safely to relieve the compression while protecting the celiac artery.

“As vascular surgeons, our expertise is to say, ‘You’re safe to keep dissecting in this area, and you need to because you’re not quite to the arterial wall yet,” Yi said. “There is still more tissue you need to get through until the artery is totally free.”

Surgical evolution for MALS 

Chauhan said open MALS surgeries began about three decades ago. Laparoscopic surgery followed, reducing recovery times and post-operative pain. Robotic surgery “changed the paradigm,” he said, by improving surgeons’ control over the instruments and providing 3D imaging and vastly improved magnification – up to 30 times greater than microscopic glasses worn by Yi compared the difference to viewing an image in 4K instead of analog.

Vascular surgeon Dr. Jeniann Yi collaborated with Dr. Chauhan to ensure a safe and ideal outcome for Anna’s median arcuate ligament syndrome surgery.
Vascular surgeon Dr. Jeniann Yi collaborated with Dr. Chauhan to ensure a safe and ideal outcome for Anna’s median arcuate ligament syndrome surgery. Photo by UCHealth.

Having a robotic-trained general surgeon work side by side with a vascular surgeon, as now happens at UCH – the only place where it occurs in Colorado – is “the next evolution” in improving patient safety and outcomes, Chauhan said.

“I believe in collaboration,” he said. “Putting two minds into a complex patient problem improves outcomes.”

“We help each other out because we’re combining our knowledge bases to help patients,” Yi added.

MALS: A mysterious malady

Anna Bajaj benefited from the work of Chauhan and Yi, but she had a long, frustrating journey to the operating table. That’s not unusual, said Dr. Max Wohlauer, a vascular surgery colleague of Yi who also works with Chauhan.

Wohlauer noted that the stomach pain and nausea that are symptoms of median arcuate ligament syndrome mimic other digestive problems and may sometimes be dismissed as psychological issues. On top of being exceedingly rare, MALS requires an extensive workup to diagnose. Providers may be baffled even after extensive investigation.

Bajaj went through around a dozen inconclusive tests over several months before Yi confirmed the diagnosis with an ultrasound scan that shows increased blood flow velocity through the celiac artery, a sign that the vessel is compressed.

“The pain makes people miserable and it takes a while to come to the diagnosis,” Wohlauer said. “When they end up in our clinic, they’ve often come to the end of their rope. They’ve tried everything and still feel miserable.”

Median arcuate ligament syndrome surgery helped to restore Anna’s time with her horses, but today the connection is restored. Photo courtesy of Anna Bajaj.
Median arcuate ligament syndrome surgery helped to restore Anna’s time with her horses. Photo courtesy of Anna Bajaj.

Symptoms of median arcuate ligament syndrome

That description could apply to Anna Bajaj. Prior to the Thanksgiving warning signs that harbingered median arcuate ligament syndrome in 2019, Bajaj described herself as “a super-active young woman” and straight-A student at Heritage High School in Littleton. Her days began early with devotion and Bible study. During her senior year, she took advanced classes in English, anatomy, physiology, and medical ethics at Arapahoe Community College.

The busy schedule, she said, “reflected my heart, my personality and the energy I had. It was all go, go, go, never slowing down.”

During that Thanksgiving weekend, Bajaj said, she noticed she lacked her normally healthy appetite. She didn’t think much of it initially, but the feeling persisted over the following month and then got worse. She began eating less frequently and by Christmas was down to one meal a day. After eating she felt nauseous, and then came the feelings of a stone in her stomach, first one large and warm, later heavy and burning. Meals brought sharp pain on both sides of her abdomen within minutes.

Each day brought a dilemma. Bajaj was so hungry because of the single daily meal regimen that she couldn’t wait to eat. But anxiety laced every food encounter because of the pain she knew was coming. Drinking was as difficult as eating, so she became dehydrated. Her physical reserves faded. Her exhaustion sidelined her from rock climbing and horseback riding.

Anna Bajaj has returned to horseback riding in shows since her surgery to treat MALS. She’s shown here at the Douglas County Fairgrounds. Photo courtesy of Anna Bajaj.
Anna Bajaj has returned to horseback riding in shows since her surgery to treat MALS. She’s shown here at the Douglas County Fairgrounds. Photo courtesy of Anna Bajaj.

Struggle to maintain the life caused by MALS

The daily attacks brought another challenge. Beginning in the fall of 2018 Bajaj had begun battling another condition called functional neurological disorder that periodically caused relatively brief bouts of paralysis. She had begun learning to manage the problem, but with the onset of her eating problems, the periods of paralysis returned more frequently.

Meanwhile, she labored to finish her senior year in high school. She had to hold the line against two difficult physical problems without sacrificing the high scholastic standards she set for herself.

With the help of understanding teachers and her enduring faith, she met her academic goals. “Trying to finish strong my senior year was the toughest thing I’ve had to do in my life so far,” Bajaj said.

Median arcuate ligament syndrome: A hard diagnosis

Bajaj was hardly a passive victim of the mysterious malady she ultimately learned was median arcuate ligament syndrome. She had her gallbladder tested before getting a referral to a gastroenterology practice in Littleton. A battery of tests and scans of her upper GI, abdomen, liver and pancreas followed, without identifying a cause or solution. During this period, from January to early March, the pain and nausea worsened.

Desperate for an answer, but getting none, Bajaj finally found Yi at the UCHealth Heart and Vascular Clinic. She calls that a “big turning point in my confidence. I felt like [Dr. Yi] really cared about me and my case and saw it as serious as I felt it was,” Bajaj said.

Yi’s examination, which included the ultrasound velocity test, confirmed median arcuate ligament syndrome. She laid out Bajaj’s options, one of which was Chauhan’s compression release surgery. The prospect of major surgery was daunting, Bajaj said, but she trusted Yi and Chauhan, particularly when she learned he had extensive experience with the MALS procedure.

That confidence was to grow. The day of the surgery, Chauhan prepared Bajaj with a diagram of what he would do to fix the problem that had vexed her for months.

“He explained things to me like I was one of his students,” she said. “He was so kind, compassionate and knowledgeable.”

Pain-free at last after median arcuate ligament syndrome procedure

After she awoke from surgery, she saw Chauhan again. He had reassuring words for her. “He told me, ‘You will feel better and will not have this pain anymore,’” Bajaj remembered.

He was right. After six months of fractured eating patterns, Bajaj says she ordered and ate two pieces of pie, a slice of cake, macaroni and cheese, Ramen noodles and Cheerios. She was stuffed, but that was the only pain she felt.

“If I wasn’t in pain from the surgery, I’d have jumped for joy,” Bajaj said.

Anna’s time with her horses has been restored thanks to her surgery. Photo courtesy of Anna Bajaj.
Anna’s time with her horses has been restored thanks to her surgery. Photo courtesy of Anna Bajaj.

Leaving MALS behind

She spent the summer resting, recuperating and fine-tuning her eating habits. With the help of her mom, Lyn, she set her schedule to ensure that she ate at least a bite or two every three hours and made sure she balanced her diet with fruits and vegetables. The pain from median arcuate ligament syndrome, blessedly, is completely gone.

In addition to making the Climbing Team at CU, Bajaj is back on the equine circuit, taking part in horse shows a couple of times a month. Her care from Chauhan and YI also yielded an unexpected side benefit: a connection with Dr. Samantha Holden, assistant professor in the Department of Neurology at CU, who has helped her better manage her functional neurological disorder.

For her part, Yi believes Bajaj contributed to her own success in surmounting the walls that MALS unexpectedly mounted before her.

“Anna was a great advocate for herself and deserves credit for being able to push her own care forward,” Yi said.

About the author

Tyler Smith has been a health care writer, with a focus on hospitals, since 1996. He served as a writer and editor for the Marketing and Communications team at University of Colorado Hospital and UCHealth from 2007 to 2017. More recently, he has reported for and contributed stories to the University of Colorado School of Medicine, the Colorado School of Public Health and the Colorado Bioscience Association.

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