What is the diagnosis and management of mesenteritis in children?

Diagnosis and Management of Mesenteritis in Children

Mesenteritis in children is a rare but significant condition requiring prompt diagnosis and targeted management to prevent complications and improve outcomes. The condition involves inflammation of the mesentery, which can present with varying symptoms and may mimic other more common abdominal conditions in children 1.

Clinical Presentation and Diagnosis

Types of Mesenteritis

• Primary Mesenteric Adenitis: Most common form in children, often self-limiting
• Secondary Mesenteric Adenitis: Associated with underlying conditions
• Complicated Primary Mesenteric Adenitis: Involves complications requiring specific management

Clinical Features

• Abdominal pain (often mimicking appendicitis)
• Abdominal tenderness and distension
• Vomiting
• Fever (may be persistent above 39°C)
• Anorexia
• Occasionally diarrhea

Diagnostic Approach

1. Imaging:

   • Ultrasonography: First-line imaging modality for suspected mesenteritis in children 2
   • CT scan: Consider when ultrasound is inconclusive or complications are suspected
   • Diagnostic criteria on ultrasound: Multiple enlarged mesenteric lymph nodes (≥6 mm in diameter) 2

2. Laboratory Testing:

   • Complete blood count (may show leukocytosis)
   • C-reactive protein and ESR (often elevated)
   • Blood cultures if systemic infection is suspected

3. Differential Diagnosis:

   • Appendicitis (most important to rule out)
   • Viral gastroenteritis
   • Intussusception
   • Mesenteric vascular occlusion (rare but serious) 3
   • Sclerosing mesenteritis (rare in children) 4

Management Approach

Primary Mesenteric Adenitis

1. Supportive Care:

   • Adequate hydration (oral rehydration therapy for mild-moderate dehydration)
   • Pain management with acetaminophen or ibuprofen
   • Rest and gradual return to normal diet as tolerated

2. Monitoring:

   • Regular assessment of vital signs
   • Evaluation of abdominal symptoms
   • Follow-up to ensure resolution of symptoms

Secondary Mesenteric Adenitis

1. Identify and Treat Underlying Cause:
   • Infectious causes: Appropriate antimicrobial therapy
   • Inflammatory conditions: Anti-inflammatory medications
   • Other causes: Directed therapy based on etiology

Complicated Mesenteric Adenitis

1. Antimicrobial Therapy:

   • For suspected bacterial infection or complications, consider broad-spectrum antibiotics 5:
     • Aminoglycoside-based regimen with metronidazole
     • Carbapenem (imipenem, meropenem, or ertapenem)
     • β-lactam/β-lactamase-inhibitor combination (piperacillin-tazobactam)
     • Advanced-generation cephalosporin with metronidazole

2. Surgical Intervention:

   • Reserved for complications such as:
     • Abscess formation requiring drainage
     • Bowel obstruction
     • Mesenteric vascular compromise 3

3. Dosing Guidelines for Children 5:

   • Piperacillin-tazobactam: 200-300 mg/kg/day of piperacillin component (divided every 6-8 hours)
   • Meropenem: 60 mg/kg/day (divided every 8 hours)
   • Metronidazole: 30-40 mg/kg/day (divided every 8 hours)
   • Ceftriaxone: 50-75 mg/kg/day (divided every 12-24 hours)

Special Considerations

Mesenteric Vascular Occlusion

• Rare but serious condition requiring urgent intervention
• Presents with severe abdominal pain, distension, and tenderness
• Requires immediate surgical consultation and possible resection of compromised bowel 3

Sclerosing Mesenteritis

• Extremely rare in children
• Characterized by fat necrosis, chronic inflammation, and fibrosis
• May require corticosteroids and tamoxifen in symptomatic cases 4

Follow-up and Prognosis

• Most children with primary mesenteric adenitis have excellent outcomes with supportive care 1
• Regular follow-up until complete resolution of symptoms
• If symptoms persist beyond 1-2 weeks, consider re-evaluation and additional imaging

Common Pitfalls to Avoid

1. Misdiagnosing as appendicitis: Careful clinical and radiological assessment is essential to avoid unnecessary surgery
2. Overuse of antibiotics: Reserve antimicrobial therapy for cases with clear evidence of bacterial infection or complications
3. Inadequate hydration: Ensure proper fluid management, especially in children with vomiting or decreased oral intake
4. Delayed recognition of complications: Maintain vigilance for signs of bowel obstruction, perforation, or vascular compromise

Most children with mesenteritis respond well to supportive care with favorable outcomes, but careful monitoring for complications is essential to prevent morbidity and mortality 1.