Case Report: Recurrent peptic ulcer perforations-a possible role of median arcuate ligament syndrome

Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome, is a rare vascular compression disorder caused by extrinsic compression of the celiac artery by the median arcuate ligament, affecting 2/100,000 people. Clinical presentation is often non-specific and may include postprandial abdominal pain, nausea, vomiting, diarrhea, and weight loss. Impaired splanchnic perfusion may contribute to gastrointestinal ischemia and, in rare cases, recurrent peptic ulcer disease. We report a patient with multiple episodes of perforated peptic ulcer disease associated with previously unrecognized MALS.

A 65-year-old man underwent six emergency abdominal operations over an 11-year period for complications of recurrent peptic ulcer disease. His initial presentation in 2013 was with a perforated duodenal ulcer managed by Graham-Roscoe patch repair. Despite subsequent interventions, including repeated ulcer repairs and antrectomy with Billroth II reconstruction, the ulcer recurred. Investigations excluded Helicobacter pylori infection and Zollinger-Ellison syndrome. In September 2024, the patient presented with severe abdominal and thoracic pain. Multislice computed tomography angiography, performed to exclude acute aortic pathology, revealed significant compression of the celiac trunk, consistent with MALS. Surgical release of the median arcuate ligament combined with truncal vagotomy was performed. At 18-month follow-up, the patient remained free of abdominal pain, dyspeptic symptoms, and further ulcer-related complications.

This case highlights MALS as a potential and often overlooked cause of refractory or recurrent peptic ulcer disease. In patients with repeated ulcer recurrence despite appropriate treatment and exclusion of common etiologies, vascular causes such as MALS should be considered. Early recognition may prevent repeated surgical interventions and improve long-term outcomes.