What is the treatment for mesenteric panniculitis?

Treatment of Mesenteric Panniculitis

Corticosteroids are the first-line treatment for symptomatic mesenteric panniculitis, with prednisone showing good clinical and radiological responses in most patients.

Diagnosis and Clinical Presentation

Mesenteric panniculitis (MP) is a rare, benign inflammatory condition affecting the fatty tissue of the mesentery, primarily in the small bowel. The diagnosis is typically based on:

• CT imaging with IV contrast showing characteristic "misty mesentery" appearance
• Biopsy in equivocal cases showing focal fat necrosis, chronic inflammation, and sometimes fibrosis
• Exclusion of other conditions that may present with similar findings

Clinical presentations include:

• Vague abdominal pain (most common)
• Nausea and vomiting
• Diarrhea or constipation
• Fever (uncommon)
• Weight loss
• Abdominal mass

Treatment Algorithm

First-Line Treatment

1. Corticosteroids
   • Prednisone (starting at 40-60mg daily with gradual taper)
   • Has shown good clinical and radiological responses during follow-up 1
   • Duration typically 2-3 months with gradual taper based on clinical response

Second-Line/Adjunctive Treatments

1. Immunomodulators

   • Azathioprine (as steroid-sparing agent)
   • Particularly useful for maintenance therapy after initial steroid response 1, 2

2. Anti-inflammatory Agents

   • Colchicine (0.5-1.0mg twice daily)
   • Can be used alone for mild cases or in combination with steroids 1

3. Novel Therapies (for refractory cases)

   • Thalidomide (has been prospectively evaluated)
   • Low-dose naltrexone (has been prospectively evaluated) 2

Surgical Management

• Generally avoided except for specific indications:
  • Relief of focal bowel obstruction due to fibrotic disease
  • Diagnostic confirmation when malignancy cannot be excluded
  • Cases refractory to medical management 2, 3
• Note: Surgery is not curative and should be limited to necessary interventions

Monitoring and Follow-up

• Clinical assessment of symptom improvement
• Follow-up CT imaging to evaluate radiological response
• Monitor for medication side effects, particularly with long-term steroid use
• Adjust therapy based on clinical and radiological response

Special Considerations

Differential Diagnosis

• Must rule out mesenteric ischemia, which may present similarly but requires urgent intervention
• Distinguish from neoplastic conditions that may mimic MP on imaging

Associated Conditions

• MP may be associated with autoimmune diseases or malignancies
• Consider screening for underlying conditions, especially in patients with family history of autoimmune disease 2

Treatment Pitfalls to Avoid

1. Delaying treatment in symptomatic patients
2. Failing to rule out mesenteric ischemia, which requires different management
3. Prolonged steroid use without attempting steroid-sparing strategies
4. Unnecessary surgical intervention, which is not curative and may worsen inflammation

Conclusion

While mesenteric panniculitis is a rare condition with limited high-quality evidence for treatment, corticosteroids remain the mainstay of therapy with good reported outcomes. Immunomodulators and other anti-inflammatory agents can be added for steroid-sparing effects or in refractory cases. Surgery should be reserved for specific indications and is not considered curative.