Hi Friend
I know what it’s like to stare at a plate of food and feel a sense of genuine fear.
For many of you, eating isn't a source of nourishment; it’s a trigger for a systemic crisis. Within minutes of a meal, you feel a crushing, sharp pain in your upper abdomen. Your heart begins to race, your skin flushes, and a wave of "impending doom" washes over you.
You’ve likely been told it’s "anxiety," "IBS," or even an eating disorder. But for those of us living with the MCAS-hEDS-POTS Trifecta, there is often a hidden mechanical culprit: Median Arcuate Ligament Syndrome (MALS).
Today, we are moving beyond the "mystery" to look at the clinical evidence of the internal squeeze.
Just before, I have the last few slots for my 1-1 clinic in April, the list will then close to focus on current patients, book here.
1. The Anatomy: The Celiac Axis Under Siege
At the centre of your upper abdomen lies the celiac artery, the master vessel that supplies oxygenated blood to your stomach, liver, and spleen. Crossing directly over this artery is the Median Arcuate Ligament (MAL)—a fibrous band of the diaphragm.
In a structurally typical body, the MAL sits high and clear of the artery. However, in patients with hypermobile Ehlers-Danlos Syndrome (hEDS), our "architecture" is different. Due to connective tissue laxity, the ligament often sits too low, or the artery sits too high.
The result is two-fold:
Vascular Ischemia: Every time you exhale, your diaphragm moves, causing the ligament to physically clamp down on the artery. This is "Intestinal Angina"—your organs are literally screaming for oxygenated blood.
Neurogenic Compression: This is the part most doctors miss. Wrapped around that artery is the celiac plexus, a dense web of nerves part of your sympathetic nervous system. MALS is as much a neuropathy as it is a vascular issue. The ligament is crushing the "command center" of your gut.
2. The Symptom Profile: More than just a "Stomach Ache"
MALS presents with a very specific, high-intensity clinical signature. Do you recognize these patterns?
Postprandial Pain: Severe epigastric pain (just below the ribs) that hits 15–30 minutes after eating.
The "MALS Thrum": A pulsing sensation or an audible "bruit" (whooshing sound) in the upper abdomen.
Food Fear & Weight Loss: Unintentional weight loss because the act of eating becomes associated with physical trauma.
The "Impending Doom" Reflex: Because the celiac plexus is being crushed, it sends a massive "Danger" signal to the brain, triggering sudden tachycardia (racing heart) and intense anxiety that has nothing to do with your thoughts.
Exercise Intolerance: Pain triggered by deep breathing or core exertion, as the diaphragm moves the ligament further into the "Squeeze Point."
3. The Systemic Domino Effect: Why MALS Triggers MCAS & POTS
MALS is rarely an isolated "gut issue." It is a systemic trigger for the entire Neuro-Somatic loop:
The Autonomic Alarm: The constant pinching of the celiac plexus keeps your nervous system in Sympathetic Overdrive. This is why your POTS symptoms may feel impossible to stabilise; your body is reacting to a physical "pinch" that it perceives as a life-or-death threat.
The Mast Cell Connection: Mast cells are hyper-concentrated around major nerves. The mechanical irritation and local lack of blood flow (ischaemia) caused by the compression trigger Mast Cell Degranulation. This is why you might flare with hives or brain fog after eating, even when the food itself is "low histamine."
4. The Diagnostic Gap: Why "Normal" Scans are the Problem
MALS is a dynamic condition, but standard hospital imaging is static.
If you have an endoscopy, a standard CT, or an ultrasound while holding your breath, your anatomy looks "normal."
To find MALS, we need Dynamic Protocols:
Mesenteric Duplex Ultrasound: This must be performed during forced inspiration and forced expiration to measure the Peak Systolic Velocity (the speed of blood) at the squeeze point.
MALS Protocol CTA/MRA: High-resolution 3D reconstructions to look for the signature "Hook Sign" (the celiac artery bending under the ligament).
5. Precision Data: The Mend ID Approach
At Mend, we utilise HRV (Heart Rate Variability) to identify the autonomic signature of MALS.
We look for a specific biometric "crash" immediately following food intake. If your HRV plummets and your RHR (Resting Heart Rate) spikes while you are experiencing epigastric pain, the data is telling us that your nervous system is reacting to a mechanical stressor, not just a digestive one.
I help patients suffering with chronic illness and am seeing a big link with chronic illness and MALS, if you would like to book a appt with me book here, the list is open but will be closing once all current dates are full.
Stay Well
Dr Ahmed
Disclaimer: Mend provides educational data and clinical insights only. This content is not a substitute for professional medical advice, diagnosis, or treatment. MALS is a structural condition that requires specialised dynamic imaging and vascular/surgical consultation. Always consult your physician before starting or changing any healthcare protocol. In an emergency, call 999 or 911 immediately.
