What is the treatment for mesenteric panniculitis?

Treatment of Mesenteric Panniculitis

Mesenteric panniculitis should be treated with corticosteroids as first-line therapy, with immunosuppressive agents such as azathioprine or colchicine added for steroid-sparing effects in chronic cases.

Understanding Mesenteric Panniculitis

Mesenteric panniculitis is a rare, benign inflammatory disorder characterized by chronic inflammation and fibrosis of the fatty tissue of the small bowel mesentery. It exists on a spectrum of mesenteric inflammatory conditions that includes:

• Early stage: Mesenteric lipodystrophy (fat necrosis)
• Middle stage: Mesenteric panniculitis (inflammation)
• Late stage: Retractile mesenteritis (fibrosis)

Diagnostic Approach

Before initiating treatment, confirmation of diagnosis is essential:

• CT with IV contrast is the primary diagnostic modality, showing characteristic "misty mesentery" with a mass-like structure at the root of the mesentery
• Deep tissue biopsy may be required in equivocal cases to rule out malignancy
• Typical histology includes focal fat necrosis, chronic inflammation, and sometimes mesenteric fibrosis 1

Treatment Algorithm

First-Line Treatment

• Corticosteroids (Prednisone): Start with 1 mg/kg/day (generally up to 80 mg/day) 2
  • Patients on prednisolone have shown good responses both clinically and radiologically during follow-up 3
  • Taper gradually based on clinical and radiological response

Second-Line/Adjunctive Treatments

1. Immunosuppressive agents:

   • Azathioprine: For steroid-sparing effects in chronic cases 3
   • Colchicine: Particularly effective for steroid-dependent cases 4
   • Combination therapy may be required in refractory cases

2. Novel therapies (for refractory cases):

   • Thalidomide
   • Low-dose naltrexone
   • These are the only agents that have been prospectively evaluated 1

Surgical Management

• Surgery is generally NOT recommended as primary treatment
• Surgical intervention should be limited to:
  • Cases with bowel obstruction due to fibrotic disease
  • Diagnostic purposes when malignancy cannot be ruled out
  • Failure of medical management with progressive symptoms 5

Monitoring and Follow-up

• Regular clinical assessment for symptom improvement
• Follow-up CT imaging to evaluate response to treatment
• Monitor for medication side effects, particularly with long-term corticosteroid use
• Consider follow-up abdominal vascular imaging in patients with severe disease who become asymptomatic 2

Special Considerations

• Exclude underlying malignancy as mesenteric panniculitis can be a paraneoplastic phenomenon
• Assess for personal or family history of autoimmune diseases, which are commonly associated 1
• Consider potential triggers such as trauma, abdominal surgery, or infection

Treatment Pitfalls to Avoid

1. Misdiagnosing mesenteric panniculitis as mesenteric ischemia or other acute abdominal conditions
2. Premature surgical intervention without adequate trial of medical therapy
3. Failure to rule out underlying malignancy
4. Inadequate duration of corticosteroid therapy (treatment may need to be prolonged)
5. Failure to add steroid-sparing agents in chronic cases

While the evidence base for treatment of mesenteric panniculitis is limited to case series and retrospective studies, the available data suggests that corticosteroids remain the cornerstone of therapy, with immunosuppressive agents providing additional benefit in chronic or steroid-dependent cases.