To differentiate median arcuate ligament compression from intrinsic disease of the celiac artery, interrogation should be performed during which breathing states?

• A. Inspiration and expiration
• B. Only expiration
• C. Valsalva maneuver
• D. Breath-hold after deep inspiration

Answer: (A)

Dynamic movement with breathing is what distinguishes median arcuate ligament compression from fixed celiac disease. The median arcuate ligament can press on the celiac artery more during exhalation (diaphragm moves up, tightening the compression) and relax during inspiration (diaphragm moves down, easing the compression). By testing Doppler velocities in both states, you’ll see the velocity rise with expiration and fall with inspiration in MAL compression. In contrast, intrinsic celiac disease shows elevated velocities that stay high regardless of breathing. So interrogating during both inspiration and expiration is the best approach to tell them apart.