Carlo DiLorenzo: Lessons Learnt Over 30 Years

Recently, Carlo DiLorenzo came to Atlanta as the speaker for the William Meyers Lectureship. He provided a terrific talk and was the perfect speaker for this lectureship which honors Billy.

Some of the key points:

  • When giving a lecture, often ‘a great study is one that supports the speaker’s view’
  • Physicians often have biases against patients with functional disorders as compared to those who have “rightful” suffering (eg. cancer, pancreatitis)
  • Key part of patient-physician relationship is listening (by the physician). Patients report better satisfaction and perceive to be understood better when a physician is sitting (while listening). “The most important technological advance in the practice of medicine was the invention of the chair. For you to sit in. While you take the history” (Mark Reid, MD)
  • Diagnoses have side effects
  • Families remember our words for years
  • We are not well-equipped to deliver good news: “This is one of the best colons I have ever seen…Your child has irritable bowel and no other tests are needed.”
  • The most under prescribed treatment: 30 minutes of physical activity everyday
  • 2nd most under prescribed treatment is a good night’s sleep.  Increased symptoms when tired
  • “Psychobezoar,” referring to a fear of discomfort with eating, could be used as an alternative to ARFID
  • Most effective treatment for IBS: cognitive behavioral therapy
  • Distraction is helpful tool for pain but need to teach parents to accept this tool
  • Some of the axioms in the lecture are attributed to Mark Reid, MD

Related blog post: #NASPGHAN19 Postgraduate Course -part 3

Here are some of the slides from this talk:

Seeing More MALS Publications

Anecdotally, I’ve seen more publications recently regarding median arcuate ligament syndrome (MALS). A recent study (JP Moak et al. J Pediatr 2021; 231: 141-147. Median Arcuate Ligament Syndrome with Orthostatic Intolerance: Intermediate-Term Outcomes following Surgical Intervention) prospectively examines the outcomes in patients with MALS and with orthostatic intolerance (OI).

Background: MALS is generally considered after other more common conditions. Typical symptoms include abdominal pain after eating or exercise and often weight loss due to fear of eating. The pain is often positional and may improve with leaning forward. The diagnostic finding of celiac artery compression may be identified in many healthy individuals (10-24% of population); thus, only severe compression, which is seen in a small number, can result in symptomatic MALS.

In this study, the key findings:

  • 31 patients with both MALS and OI were identified from 2014-2019. Median f/u after surgery was 22 months.
  • Based on questionnaires, gastrointestinal symptoms of abdominal pain, nausea, and vomiting improved in 63% (P = .007), 53% (P = .040), and 62% (P = .014) of patients, respectively. 
  • Based on questionnaires, cardiovascular symptoms of dizziness, syncope, chest pain, and palpitations improved in 45% (P = not significant), 50% (P = not significant), 54% (P = .043), and 54% (P = .037) of patients, respectively.
  • Importantly, the authors could not demonstrate a “statistical relationship between a postoperative decrease in celiac artery Doppler velocity and improvement in clinical symptoms.”
  • In an effort to gauge for a potential post-surgical placebo effect, the authors determined the degree of improvement in musculoskeletal symptoms. There was a 24% improvement which was much less than the improvement in GI symptoms.

One useful feature of this article is that the authors explicitly state how they arrive at the diagnosis of MALS. They start with an abdominal ultrasound with doppler. Criteria for suspected MALS include supine celiac artery peak systolic velocity of >300 cm/s, celiac artery/aoritic peak systolic ratio of >3:1, neutral position celiac artery peak systolic velocity of >200 cm/s, and a change in the celiac artery deflection angle of >50 degrees between inspiration and expiration. If ultrasound is abnormal, the authors obtained an enhanced CT to image inspiratory and expiratory changes in the celiac artery deflection angle, the area of stenosis, poststenotic dilation, and the collateral blood vessels. If there are discrepancies between U/S and CT, a celiac arterial angiogram is obtained.

The authors conclude that there “were minimal improvements in neurologic or psychological symptoms after MALS surgery, despite their common occurrence among patients with POTS.”

My take: This study, in agreement with others, showed that about 60% had improvement in GI symptoms including pain, nausea and vomiting. In those with OI, most continued with impaired health. Overall, MALS as a clinical entity remains a ‘needle in a haystack.’

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