Severe celiac trunk stenosis following blunt trauma in a patient with diabetic ketoacidosis: a diagnostic dilemma of traumatic injury versus median arcuate ligament syndrome.

Introduction: Severe proximal celiac trunk stenosis or occlusion following blunt trauma is exceedingly rare, with potential etiologies including acute traumatic vascular injury, thrombosis, and underlying median arcuate ligament syndrome (MALS). In patients complicated by type 1 diabetic ketoacidosis (DKA), overlapping symptoms such as nausea and vomiting may arise from both metabolic derangement and visceral hypoperfusion, frequently obscuring the underlying vascular pathology and complicating diagnostic decision-making. Methods: We report the case of a 33-year-old man with poorly controlled type 1 diabetes mellitus who sustained multiple blunt injuries after being crushed by an approximately 400-kg object, resulting in sternal, rib, and pelvic fractures with hemoperitoneum. He developed persistent nausea, vomiting, and hyperglycemia, and was initially diagnosed with DKA. Despite correction of metabolic abnormalities with insulin therapy, fluid resuscitation, and acid-base balance, gastrointestinal symptoms persisted, prompting dedicated abdominal contrast-enhanced computed tomography (CT) and CT angiography (CTA). Results: Imaging revealed severe proximal celiac trunk stenosis (approximately 80% luminal narrowing) with near-occlusion, post-stenotic dilatation, a fish-hook configuration, and extensive collateral circulation, without definite intimal flap, thrombus, or atherosclerotic plaque. These findings were suggestive of pre-existing MALS with trauma-induced decompensation, although acute traumatic injury could not be entirely excluded. Following multidisciplinary evaluation, conservative management - comprising glycemic control, fluid resuscitation, antiemetic therapy, and nutritional support - was pursued given hemodynamic stability, preserved collateral perfusion, and absence of end-organ ischemia. Gastrointestinal symptoms resolved completely by hospital day 7. The patient subsequently underwent successful closed reduction and internal fixation of pelvic fractures and was discharged on postoperative day 3 without vascular intervention. Conclusion: His case underscores the diagnostic challenge posed by concurrent DKA and suspected MALS in the setting of blunt trauma. Celiac trunk dysfunction should be considered in patients with high-energy trauma who experience persistent nausea or vomiting after metabolic correction, even without hemodynamic instability or overt abdominal signs. Early contrast-enhanced CT/CTA is essential for timely diagnosis, and in carefully selected patients with adequate collateral circulation and no evidence of ischemia, individualized conservative management can be a safe and effective strategy. Multidisciplinary collaboration among trauma, vascular, endocrinology, and radiology teams is crucial for optimal management of such complex cases.