Imagine feeling constantly horrible, unable to keep down anything you eat or drink, living in a cycle of terrible heaves that leave your chest and abdomen aching. That was the reality for a young woman who, at just 21, found herself trapped in a nightmare of unremitting vomiting that began after a minor car accident.
For three months, she had been going to emergency rooms repeatedly, seven times in total. Each visit brought her temporary relief with IV fluids, but no answers, and the vomiting always returned. Doctors initially suspected anxiety, her long – standing psychiatric disorder, and she was sent home twice after hospital admissions without a diagnosis, only to continue vomiting everything.
Determined to find help, she took her father’s advice and traveled from Atlanta back home to Cleveland just before Thanksgiving. Her regular doctor, Ellen Rome, head of the Center for Adolescent Medicine at Cleveland Clinic Children’s Hospital, wasn’t in but arranged for her to see a pediatric gastroenterologist, who immediately admitted her.
The medical team began considering the possibilities for such persistent vomiting. They thought about psychogenic vomiting linked to anxiety, regular marijuana use, excessive vomiting in pregnancy (hyperemesis gravidarum), and hyperthyroidism. They ran tests, and the results started coming in the next morning.
She was not pregnant, and importantly, there was no evidence of marijuana in her system, ruling out cannabis – induced vomiting syndrome. Her thyroid tests and other routine studies also came back normal. The mystery deepened, but Dr. Rome had a crucial piece of information.
When the young woman had been hospitalized in Atlanta, one of her scans showed an unusual finding: her celiac artery, which supplies blood to many digestive organs, appeared strangely narrowed, as if something outside was compressing it. This finding was suggestive of a rare disorder called median arcuate ligament syndrome, or MALS.
Dr. Rome explained that MALS occurs when the median arcuate ligament, a band of connective tissue anchoring the diaphragm to the spine, presses on the celiac artery. While MALS is usually known for causing severe abdominal pain, the compression of this vital artery could definitely cause the extreme nausea and vomiting she had been experiencing.
The theory was that when the digestive organs and nerves needed the most blood — right after eating — the compressed artery might be starving them. Despite this compelling clue, the doctors in Atlanta had considered anxiety a much more likely cause than this rarity. However, they had suggested a specialized ultrasound to check blood flow.
This specialized test hadn’t been completed before she left Atlanta, so Dr. Rome insisted it be done now in Cleveland. The test uses Doppler ultrasound, which employs sound waves to measure blood – flow speed by detecting changes in pitch. When breathing in, the diaphragm moves down, and blood flow should be normal or even faster through a partly obstructed artery, like water speeding up when you partially block a hose.
But when breathing out, the diaphragm moves up. In MALS, this movement can reduce or even completely stop blood flow through the compressed celiac artery, depriving the digestive organs and nerves of the necessary blood and oxygen for digestion. The ultrasound results came back, but they were inconclusive.
The young woman felt frustrated and confused. Part of her was relieved that nothing definitive was wrong, but another part worried because they still didn’t understand her condition. By this point, she had been in the hospital for three days, still unable to eat or drink. To provide her with nutrition, doctors inserted a tube through her nose into her stomach for liquid feeding and to give her water.
She had to return to school with the feeding tube, finding it uncomfortable and embarrassing, but acknowledging it was better than the constant vomiting. Dr. Rome visited her and, despite the inconclusive ultrasound, remained convinced that she had MALS. Dr. Rome had only seen the report of the earlier CT scan and needed to see the actual images to confirm the compression.
So, Dr. Rome ordered another CT scan. On the day before Thanksgiving, the patient had the scan, which took pictures when she inhaled and again when she exhaled. These images finally provided the conclusive diagnosis they had been seeking: She had MALS, confirming the compression of her celiac artery by the median arcuate ligament.
The next step was a test to confirm the diagnosis and predict if surgery would help. This involved injecting an anesthetic into the celiac plexus, a bundle of nerves supplied by the celiac artery. If blocking these nerves stopped the nausea and vomiting, it would strongly suggest that surgically releasing the ligament compressing the artery could be curative.
This procedure couldn’t be scheduled over the holiday, so she went home to celebrate Thanksgiving with her family. She could only watch as they enjoyed turkey and stuffing, knowing that even a single bite would trigger her symptoms. After returning to school, Dr. Rome arranged for the nerve block injection to be done over the Christmas holiday by the gastroenterologist chosen for the potential surgery.
And then, a moment of pure joy and hope arrived. After the injection, for the first time in months, she could eat and drink! Her mother brought her all her favorite treats: sour cream and onion Pringles, a large iced coffee, and ice cream. It was an incredible day, a taste of normal life, and it filled her with optimism that surgery would provide a permanent cure.
Her surgery was scheduled for February. The procedure aimed to loosen the median arcuate ligament, freeing the compressed celiac artery. As soon as she awoke in the recovery room, she was given a cup of apple juice. She drank it, and she felt fine. After nearly two years of relentless suffering, the vomiting was finally over.
The precise reason why she suddenly developed MALS after the car accident remains somewhat unclear. There are documented cases of MALS being triggered by physical trauma, and perhaps the accident, even if seemingly minor, was enough to affect the alignment of her diaphragm and celiac artery. Sometimes, medicine can figure out what is wrong and how to fix it, but the underlying why can remain a puzzle.
But for this young woman, the long and difficult journey to diagnosis and treatment brought immense relief. After years of debilitating symptoms and unanswered questions, she finally had her life back, free from the constant, agonizing cycle of vomiting. Her story is a powerful reminder of the importance of persistent investigation in the face of medical mysteries and the incredible impact a correct diagnosis and successful treatment can have.
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