Why did the young woman vomit up everything she ate or drank?

The flight to Cleveland was quick. Her father picked her up at the airport and drove straight to Cleveland Clinic Children’s. Her regular doctor, Ellen Rome, the director of the Center for Adolescent Medicine there, was out of the office that holiday week but arranged for the young woman to see a pediatric gastroenterologist. She admitted her to the hospital immediately.

The doctor who admitted her that night considered possible causes for this kind of persistent vomiting. The patient was taking anti-anxiety medication, so maybe the doctors in Atlanta were right—maybe this was psychogenic vomiting, caused by her long-standing psychiatric disorder. But there were other possibilities. Regular marijuana use could cause persistent vomiting. Hyperemesis gravidarum—excessive vomiting during pregnancy—was also possible. Those were easy to test for. Hyperthyroidism can also cause this kind of vomiting. The next morning, the test results started trickling in. She was not pregnant and had no evidence of marijuana in her system. Her thyroid was normal. So were the rest of the more routine tests.

That morning, Rome contacted the team assigned to care for the young woman. When she was admitted to Emory Hospital, Rome explained, one of her scans showed an unusual finding. Her celiac artery, which supplies blood to many digestive organs, was strangely narrowed, as if being compressed from the outside. That pointed to a rare condition called median arcuate ligament syndrome (MALS), in which the connective tissue that anchors the diaphragm to the spine—the median arcuate ligament—encroaches on the celiac artery. Though it’s usually characterized by severe abdominal pain, compression of that vital artery can cause the kind of nausea and vomiting she was experiencing by depriving downstream nerves and organs of enough blood when they need it most—right after eating.

Despite the abnormal scan, doctors at Emory thought it was far more likely that she had some kind of anxiety-induced vomiting than this rarity. Still, they had suggested a specialized type of ultrasound to see if the compression was affecting blood flow through the artery. That hadn’t been done when the patient came to Cleveland. They had to do it now, Rome said. The test was done the next day.

Using sound waves, Doppler ultrasound allows doctors to estimate how fast the blood is flowing by measuring the rate of change in pitch or frequency. The diaphragm moves up when air is inhaled, and so blood flow through the celiac artery would be normal or, if partially blocked, faster than normal, much like water flowing through a hose would flow faster if you use your thumb to partially block the opening. But when you exhale, the diaphragm moves down, and in MALS this will reduce or even stop blood flow through the artery, depriving the target organs or nerves of the blood and oxygen they need to digest food.

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