It often starts with a symptom that feels out of place. A sharp abdominal pain after a meal, persistent flank pressure, or a streak of blood in the urine that doesn’t make sense. For a small number of people, these clues point to vascular compression syndromes. Rare conditions that occur when major blood vessels are compressed enough to disrupt normal circulation. Two of the most often confused vascular compression syndromes are Median Arcuate Ligament Syndrome (MALS) and Nutcracker Syndrome (NCS). 

Though both of these conditions involve blood vessel compression, they affect different parts of the body and cause very different problems. Fewer than two out of 100,000 people are diagnosed with MALS each year, and Nutcracker Syndrome is similarly rare but frequently underrecognized. Finding a provider who can distinguish between them matters because a missed or mistaken diagnosis can lead to years of unexplained pain and unnecessary testing. 

Read on to learn about MALS and NCS symptoms, how they’re diagnosed, treatment options, and where to find the best MALS treatment doctor in Los Angeles. 

MALS and Nutcracker Syndrome: Understanding Their Causes

With MALS, a band of tissue called the median arcuate ligament presses down on the celiac artery, the main vessel that supplies blood to the stomach, liver, and other upper abdominal organs. Normally, this ligament arches above the artery, but in some people, it can sit lower and compress the vessel. This pressure can reduce blood flow to vital organs and irritate the nearby bundle of nerves known as the celiac plexus, leading to pain that often worsens after eating. Those who have had bariatric surgery are at a high risk of developing this condition. 

In contrast, Nutcracker Syndrome (NCS) involves compression of the left renal vein, typically between the abdominal aorta and the superior mesenteric artery. That squeeze causes blood to back up into smaller veins, raising pressure in the kidneys and sometimes the pelvis. Some people develop the anterior form of NCS, where the vein is trapped between the aorta and the SMA, while others have the rarer posterior form, where it’s compressed behind the aorta near the spine. 

The key difference between these two conditions is that MALS affects an artery and nearby nerves, while NCS involves a vein under pressure. 

Symptoms of MALS and Nutcracker Syndrome

For people living with MALS, pain often begins after eating and is described as a deep ache or cramp that builds under the ribs and can make every bite feel like too much. Meals that once felt comforting become stressful, and over time, many lose weight without trying. Some people also feel nauseated, lightheaded, or experience pain during exercise when blood flow shifts through the abdomen.

With NCS, the symptoms feel different but are just as disruptive. Blood in the urine is one of its hallmark signs, often accompanied by a dull ache in the left flank or lower back. Women may notice pelvic pressure or visible veins around the pelvis, while men sometimes develop a swollen vein near the testicle. Some people with the anatomical compression never develop symptoms, while others face chronic pain and uncertainty as they search for answers. 

Because both MALS and NCS can cause vague abdominal discomfort and share similar vascular pathways, some patients spend years being tested for other conditions before the real cause is found.

How are MALS and Nutcracker Syndrome Diagnosed?

Diagnosing MALS often begins after other gastrointestinal causes, like gallbladder disease or acid reflux, have been ruled out. Many patients arrive at this stage after months or even years of testing, still searching for an explanation for their pain. 

Diagnostic tools that can help with diagnosis include:

  • A Doppler ultrasound to measure how fast blood moves through the celiac artery. When that flow spikes during breathing or after eating, it can signal compression.
  • A CT or MRI angiogram (MRA) may reveal the telltale hook-shaped bend of the artery caused by the ligament pressing against it. 

Testing for NCS focuses on the veins instead of the arteries, but also uses the same diagnostic tools: 

  • A Doppler ultrasound or CT/MR venogram can both show the left renal vein being squeezed between larger vessels and whether blood is backing up into nearby veins. 
  • An intravascular ultrasound (IVUS) can also diagnose NCS by threading a small probe inside the vein to measure pressure and see the walls directly. 

When diagnosing MALS, imaging shows how an artery and surrounding nerves are compressed, while NCS studies show how blood flow slows and pressure builds in the renal vein.

Treatment Options for MALS and Nutcracker Syndrome

​​Treatment for MALS depends on how much the artery and nearby nerves are being compressed and how strongly symptoms affect daily life. The most common approach is surgery to release the ligament that’s pressing on the celiac artery, sometimes paired with removing part of the nearby nerve bundle to reduce pain. In certain cases, the best MALS treatment specialist in Los Angeles may also rebuild or bypass the artery if blood flow remains limited after the release. The great news is that most people experience lasting relief once pressure is removed. 

Nutcracker Syndrome is treated differently because it affects the veins rather than the arteries. For mild or early cases, especially in children, doctors often recommend close observation, as some patients outgrow the compression as they gain weight or their anatomy shifts with age. When symptoms like persistent flank pain or blood in the urine become more severe, surgical options may include moving the affected vein to a new position, placing a stent to open it, or rerouting blood flow through another vessel. 

Can You Have MALS and Nutcracker Syndrome at the Same Time?

In rare cases, a person can have MALS and NCS at the same time. This creates a confusing overlap of symptoms that don’t fit neatly into one diagnosis. When this happens, patients may experience a mix of abdominal pain after meals, nausea, and flank discomfort or blood in the urine. Symptoms that all seem unrelated until imaging reveals both arterial and venous compression. Because these syndromes are uncommon, many patients spend years seeing different specialists before someone connects the dots. 

Finding the Best MALS Treatment Doctor in Los Angeles

Every MALS case carries its own challenges, which is why patients across Los Angeles trust Dr. Danny Shouhed to navigate this complex condition with clarity and care. As a leader in robotic and minimally invasive gastrointestinal surgery, we combine advanced technical skill with a deep understanding of the delicate anatomy involved in median arcuate ligament syndrome. 

Dr. Shouhed’s background as a fellowship-trained surgeon from top institutions like Cedars-Sinai and Mount Sinai means you’re working with a specialist who not only performs these surgeries regularly but also advances the field through research and innovation. 

Ready to get thoughtful guidance and surgical expertise designed to bring lasting relief with the best MALS treatment doctor in Los Angeles?