What is the treatment for mesenteric panniculitis?

Treatment for Mesenteric Panniculitis

Corticosteroids (prednisone) are the first-line therapy for symptomatic mesenteric panniculitis, starting at 1 mg/kg/day (up to 80 mg/day) with gradual tapering based on clinical and radiological response. 1

Understanding Mesenteric Panniculitis

Mesenteric panniculitis is a rare, benign inflammatory disorder characterized by chronic inflammation and fibrosis of the fatty tissue in the small bowel mesentery. It exists on a spectrum of mesenteric inflammatory conditions including mesenteric lipodystrophy, mesenteric panniculitis, and retractile mesenteritis.

Diagnostic Confirmation

Before initiating treatment, diagnosis should be confirmed through:

• CT scan with IV contrast (primary diagnostic tool) showing "misty mesentery" with mass-like structure at the root of the mesentery
• Deep tissue biopsy in equivocal cases to rule out malignancy

Treatment Algorithm

First-Line Therapy

• Corticosteroids: Prednisone 1 mg/kg/day (generally up to 80 mg/day) 1
  • Taper based on clinical and radiological response
  • Monitor for steroid-related side effects

Second-Line/Adjunctive Therapy

• Immunosuppressive agents for steroid-sparing effects in chronic cases:
  • Azathioprine
  • Colchicine 1, 2

Refractory Cases

• Combination therapy with multiple agents 1, 2
• Consider surgical intervention only when:
  • Medical therapy fails completely
  • Complications such as bowel obstruction occur
  • Diagnostic uncertainty persists 3

Monitoring and Follow-up

• Regular clinical assessment for symptom improvement
• Follow-up CT imaging to evaluate treatment response
• 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 1

Important Considerations and Pitfalls

Rule Out Other Conditions

• Exclude underlying malignancy as mesenteric panniculitis can be a paraneoplastic phenomenon
• Assess for personal or family history of autoimmune diseases, which are commonly associated

Potential Triggers to Identify

• Trauma
• Abdominal surgery
• Infection 1

Common Pitfalls

1. Misdiagnosing mesenteric panniculitis as mesenteric ischemia or other acute abdominal conditions
2. Premature surgical intervention when medical management would suffice
3. Failure to rule out underlying malignancy

Prognosis

Most patients respond well to medical therapy, particularly corticosteroids 2. Surgery is rarely needed and should be reserved for specific complications or when diagnosis remains uncertain despite imaging and other workup 3.