Synopsis
Distinguish incidental coeliac compression from a carefully selected symptomatic syndrome and sequence dynamic imaging, exclusion of common disease and specialist treatment decisions.
- MALS is a diagnosis of exclusion: do not convert incidental coeliac indentation into a pain diagnosis.
- The complete ESVS selection requires postprandial pain plus food modification, unexplained weight loss or unexplained diarrhoea; at least 70% external coeliac stenosis on two imaging techniques including inspiratory and expiratory 1 mm CTA; and normal abdominal ultrasound and gastroscopy. Imaging alone is insufficient.
- Start with mesenteric duplex during inspiration and expiration, then use a specialist MDT. Surgery may be considered only for selected confirmed MALS (class IIb, level C); when operating, laparoscopic or video-assisted retroperitoneal release may be preferred, and release precedes any selected revascularisation.
Key red flags
Pain with guarding, shock, metabolic deterioration, gastrointestinal bleeding or CT bowel-ischaemia signs requires emergency assessment for another diagnosis.
Progressive weight loss, anaemia, nocturnal symptoms, dysphagia, persistent vomiting or a mass requires exclusion of malignancy and gastrointestinal disease.
Atherosclerotic risk factors or multivessel mesenteric stenosis suggest occlusive chronic mesenteric ischaemia rather than isolated external compression.
Coeliac compression on a single scan without the selected symptom pattern is an anatomical observation, not proof of MALS.
Primary coeliac stenting before adequate ligament release risks persistent external compression, stent fracture or disconnection.
Sudden severe pain, shock, peritonism or bowel injury on CT suggests acute mesenteric ischaemia, perforation, pancreatitis or another emergency rather than uncomplicated MALS.
Investigation priorities
Demonstrate dynamic coeliac compression as the first vascular examination.
Management branches
A young adult has meal-related pain, food avoidance, weight loss and coeliac indentation reported on routine CT.
- First separate emergency features and document timing, meal relation, weight trajectory, bowel symptoms, vascular risk and previous investigations; incidental compression alone is not the answer.
- Exclude plausible gastrointestinal disease, including abdominal ultrasound and gastroscopy, then obtain expert mesenteric duplex during inspiration and expiration.