What is the treatment for mesenteric panniculitis?

Treatment of Mesenteric Panniculitis

First-line treatment for mesenteric panniculitis is oral prednisone 40 mg daily, with tamoxifen often used as an adjunctive therapy for symptomatic cases. 1

Clinical Presentation and Diagnosis

Mesenteric panniculitis (MP) is a benign condition characterized by chronic inflammation and fibrosis of adipose tissue, primarily affecting the small bowel mesentery. The clinical presentation varies:

• Common symptoms:

  • Abdominal pain (most frequent)
  • Bloating/distention
  • Diarrhea or constipation
  • Vomiting, anorexia, weight loss
  • Fever, malaise, nausea

• Diagnostic imaging:

  • CT with IV contrast is the preferred modality
  • Characteristic findings: mass-like area of increased fat attenuation within small bowel mesentery
  • Often located in left upper quadrant
  • "Misty mesentery" appearance with small associated lymph nodes

• Differential diagnosis:

  • Lymphoma (most common differential)
  • PET/CT may be needed if malignancy is suspected

Treatment Algorithm

1. Asymptomatic Patients

• Observation only (up to 50% of cases are asymptomatic) 1
• Regular follow-up to monitor for symptom development

2. Symptomatic Patients

• First-line medical therapy:

  • Prednisone 40 mg daily 2
  • Duration: Typically 1 month, with gradual tapering based on clinical response
  • Monitor for symptom improvement (usually occurs within 1 month)

• Adjunctive therapy:

  • Tamoxifen (often combined with prednisone) 1
  • Azathioprine or colchicine for steroid-sparing or refractory cases 3

3. Refractory Cases

• Combination therapy with multiple immunosuppressive agents 3
• Consider surgical consultation if medical therapy fails

4. Surgical Management

• Reserved for specific indications:
  • Recurrent bowel obstruction 1
  • Failure of medical therapy with persistent severe symptoms 3
  • Diagnostic uncertainty requiring tissue confirmation
  • Surgical approach: Partial resection of affected bowel segment when necessary 4

Monitoring and Follow-up

• Clinical assessment of symptom improvement
• Follow-up CT scan to evaluate radiological response
• Weight monitoring (weight gain may indicate successful treatment) 2
• Gradual tapering of steroids based on clinical and radiological improvement

Treatment Efficacy and Prognosis

• Most patients respond well to medical therapy, particularly corticosteroids 2, 3
• Overall prognosis is generally good with appropriate treatment
• Recurrence appears to be rare after successful treatment 2
• Only a small percentage of patients require surgical intervention 3

Important Considerations

• Rule out underlying malignancy, as MP can sometimes be associated with concurrent cancer
• Individualize treatment duration based on symptom response
• Monitor for steroid-related side effects if long-term therapy is required
• Consider steroid-sparing agents for prolonged treatment courses
• Surgical intervention should be limited to cases with specific indications, as the disease is generally benign

The treatment approach should be guided by symptom severity, with most patients responding well to corticosteroid therapy. Surgery should be reserved for cases with complications or failure of medical management.