What is the treatment for Mesenteric panniculitis?

Treatment of Mesenteric Panniculitis

First-line medical treatment for symptomatic mesenteric panniculitis is prednisone and tamoxifen, with surgery reserved only for cases of recurrent bowel obstruction or when medical therapy fails. 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 condition presents with varying symptoms:

• Common symptoms: Abdominal pain (most frequent), bloating/distention, diarrhea, constipation
• Less common symptoms: Vomiting, anorexia, weight loss, fever, malaise, nausea 1
• Important note: Up to nearly half of patients may be asymptomatic, with MP discovered incidentally on imaging 1

Diagnostic Approach

• CT imaging: Primary diagnostic tool showing:

  • Mass-like area of increased fat attenuation within small bowel mesentery
  • Usually located in left upper quadrant
  • Envelopment of mesenteric vessels
  • Displacement of adjacent bowel segments
  • Frequently visible lymph nodes within the affected area 1

• PET/CT: May be warranted if there's suspicion of concurrent malignancy, particularly lymphoma 1, 2

• Surgical biopsy: Often required for definitive diagnosis in equivocal cases 3, 4

Treatment Algorithm

1. Asymptomatic Patients

• Observation only
• Regular follow-up to monitor for symptom development or complications 1

2. Symptomatic Patients

Medical Management (First-Line):

• Corticosteroids: Prednisone is the primary treatment 1, 4
• Tamoxifen: Often used in combination with prednisone 1
• Alternative/Adjunctive options:
  • Azathioprine
  • Colchicine
  • Combination therapy 4

Monitoring Treatment Response:

• Clinical symptom improvement
• Follow-up imaging to assess radiological response 4

3. Refractory or Complicated Cases

• Surgical intervention: Reserved for:

  • Recurrent bowel obstruction
  • Failure of medical therapy
  • Cases requiring emergency intervention 1, 5

• Surgical approach: Typically involves partial bowel resection of the affected segment 5

Special Considerations

Association with Malignancy

• MP has been associated with malignancies, particularly lymphomas 2
• Thorough evaluation for underlying malignancy should be considered, especially in patients with:
  • Atypical presentation
  • Poor response to standard therapy
  • Risk factors for malignancy 2

Emergency Presentations

• MP can mimic acute abdominal conditions including:
  • Small bowel obstruction
  • Mesenteric ischemia 5
• Emergency surgery may be required in these scenarios, typically involving partial jejunal resection 5

Treatment Outcomes

• Patients treated with prednisone typically show good clinical and radiological responses during follow-up 4
• Most patients respond well to medical management, with surgery rarely required 4
• One study reported only 1 out of 40 patients required surgical intervention after failing medical therapy 4

Pitfalls to Avoid

• Misdiagnosis as lymphoma or other malignancy
• Unnecessary aggressive surgical intervention for what is fundamentally a benign condition
• Failure to consider MP in the differential diagnosis of chronic abdominal pain
• Inadequate follow-up of patients with incidentally discovered MP

The treatment approach should be guided by symptom severity and presence of complications, with medical management as the cornerstone for most patients and surgery reserved for specific indications.