What is the recommended management approach for chronic mesenteric panniculitis?

Management of Chronic Mesenteric Panniculitis

Corticosteroids, particularly prednisone, should be considered the first-line treatment for symptomatic chronic mesenteric panniculitis, with tamoxifen as a potential adjunctive therapy.

Diagnosis and Clinical Presentation

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:

• Up to 50% of patients may be asymptomatic (incidental finding on imaging) 1
• Common symptoms include:
  • Abdominal pain (most frequent)
  • Bloating/distention
  • Altered bowel habits (diarrhea or constipation)
  • Nausea/vomiting
  • Weight loss
  • Fever and malaise

Diagnostic Approach

1. Imaging:

   • CT scan with IV contrast is the primary diagnostic tool 1, 2
   • Typical findings: mass-like area of increased fat attenuation within small bowel mesentery, usually in left upper quadrant
   • "Misty mesentery" appearance with fat stranding
   • Preservation of fat around mesenteric vessels ("fat ring sign")

2. Differential Diagnosis:

   • Lymphoma (most important to exclude)
   • Mesenteric carcinomatosis
   • Infectious processes
   • Mesenteric edema from other causes

3. Confirmatory Testing:

   • Surgical biopsy may be required in equivocal cases 3
   • PET/CT if underlying malignancy is suspected 1

Treatment Algorithm

1. Asymptomatic Patients

• Observation only
• Regular follow-up to monitor for symptom development
• No medical intervention required 1

2. Symptomatic Patients - First Line Therapy

• Corticosteroids: Prednisone (starting at 40mg daily with gradual taper over 8-12 weeks) 2, 4
  • Evidence shows convincing immediate symptomatic response 4
  • Most effective in early inflammatory stages before extensive fibrosis develops
  • Monitor for clinical and radiological improvement during follow-up

3. Adjunctive or Alternative Therapies

• Tamoxifen: Often used in combination with prednisone 1, 5
• Immunomodulators: Azathioprine (1.5-2.5 mg/kg/day) for steroid-dependent disease 6, 2
• Anti-inflammatory agents: Colchicine has shown benefit in some cases 2
• Novel therapies: Thalidomide and low-dose naltrexone have been prospectively evaluated 5

4. Treatment for Refractory Cases

• Combination therapy (corticosteroids plus immunomodulators)
• Trial of hormonal therapy
• Consider low-dose naltrexone if other options fail 5

5. Surgical Management

• Reserved for complications such as:
  • Recurrent bowel obstruction
  • Cases unresponsive to medical therapy
  • When diagnosis remains uncertain despite imaging 1, 2
• Surgical approach is limited and not curative 5
• Conservative resection limited to macroscopically affected segments when necessary 6

Monitoring and Follow-up

• Regular clinical assessment of symptom response
• Follow-up CT imaging to evaluate treatment response
• Monitor for potential side effects of medications
• Long-term follow-up to detect potential disease recurrence

Important Considerations

• Early treatment with corticosteroids before extensive fibrosis develops offers better outcomes 4
• The inflammatory phase of MP is more responsive to medical therapy than the fibrotic phase
• Patients with active inflammation (fever, elevated ESR, predominance of inflammatory cells on histology) are more likely to respond favorably to steroid treatment 4
• Surgical intervention should be avoided except for relief of focal bowel obstruction secondary to fibrotic forms of the disease 5

Pitfalls to Avoid

• Delaying treatment in symptomatic patients
• Prolonged steroid use without attempting steroid-sparing strategies
• Unnecessary surgical intervention for a condition that often responds to medical management
• Failure to exclude underlying malignancy, particularly lymphoma

The evidence strongly supports that corticosteroids provide the most reliable clinical response in symptomatic mesenteric panniculitis, particularly when initiated before extensive fibrosis has developed 4.