The flight to Cleveland was short; her father met her at the airport and took her straight to Cleveland Clinic Children's Hospital. Her doctor, Ellen Rome, director of the hospital's Center for Adolescent Medicine, was out of town for the holiday week, but she arranged for the young woman to be seen by a pediatric gastroenterologist and was quickly admitted.
The doctor who admitted her that night pondered the cause of this nonstop vomiting. The patient was taking medication for anxiety, so perhaps the Atlanta doctors were right. It could be psychogenic vomiting caused by a long-standing psychiatric disorder. But there were other possibilities. Regular marijuana use could cause persistent vomiting. She could have hyperemesis gravidarum (excessive vomiting during pregnancy). These were easy to test for. Hyperthyroidism can also cause this type of vomiting. By the next morning the test results were trickling in. She was not pregnant, there was no trace of marijuana in her system. Her thyroid was normal. So were the other routine test results.
That morning, Rome contacted the team responsible for the young woman's care. When she was admitted to Emory, Rome explained, her scans showed something unusual: her celiac artery, which supplies blood to many of her digestive organs, was strangely narrowed, as if it was being compressed from the outside. This suggested a rare condition called median arcuate ligament syndrome (MALS), in which the median arcuate ligament, the connective tissue that attaches the diaphragm to the spine, compresses the celiac artery. Typically characterized by severe abdominal pain, compression of this vital artery can mean that downstream nerves and organs don't get enough blood when they need it most — after eating — and can lead to the nausea and vomiting she experienced.
Despite the abnormal scan, doctors at Emory University thought the vomiting was far more likely to be anxiety-related than an unusual case. Still, they suggested a special ultrasound to see if the pressure was affecting blood flow in the arteries. That hadn't been done when the patient arrived in Cleveland. It needed to be done now, Rome said. The test was performed the next day.
Repeated scans
Doppler ultrasound uses sound waves to help doctors estimate how fast blood is flowing by measuring the rate of change of the pitch or frequency of blood flow. When you breathe in, the diaphragm rises so blood flows normally through the celiac artery, but if it's partially blocked it will be faster than normal, just like water speeds up through a hose when you partially block the opening with your thumb. But when you breathe out, the diaphragm drops, and in MALS, this reduces or stops blood flow through the artery, depriving the target organ or nerve of the blood and oxygen it needs to digest food.
