What is the diagnosis and treatment approach for mesentery panniculitis?

Mesenteric Panniculitis: Diagnosis and Treatment Approach

Mesenteric panniculitis should be treated with oral prednisone at 40 mg daily as first-line therapy, with clinical improvement typically occurring within one month. 1

Diagnosis

Clinical Presentation

• Most common symptoms:
  • Abdominal pain (most frequent)
  • Bloating/distention
  • Diarrhea or constipation
  • Nausea and vomiting
  • Anorexia and weight loss
  • Fever and malaise 2
• Up to 50% of cases may be asymptomatic and detected incidentally on imaging 2

Diagnostic Workup

1. Imaging:

   • CT scan with IV contrast is the primary diagnostic tool
   • Characteristic findings: mass-like area of increased fat attenuation within small bowel mesentery (usually in left upper quadrant), enveloping mesenteric vessels and displacing adjacent bowel segments 2
   • Lymph nodes frequently seen within the area of mesenteric abnormality

2. Biopsy:

   • Deep excisional biopsy with large amount of tissue is essential for histopathological evaluation 3
   • Helps determine the specific type of panniculitis and guide treatment
   • May be required to rule out malignancy (particularly lymphoma)

3. Laboratory Testing:

   • Alpha-1 antitrypsin (AAT) levels should be tested in all cases of biopsy-proven severe panniculitis 3
   • Important to rule out AAT deficiency, as treatment approach differs significantly

Treatment Algorithm

First-line Treatment

• Corticosteroids: Prednisone 40 mg daily 1, 4
  • Clinical improvement typically occurs within 1 month
  • Gradually taper with goal of achieving low-dose (≤10 mg/day) or complete withdrawal 3
  • For severe cases: Consider IV pulse methylprednisolone 500-1000 mg/day for 3-5 days before transitioning to oral prednisone 3

Alternative/Additional Therapies

• Immunosuppressants:
  • Azathioprine (can be used alone or in combination with prednisone) 4
  • Tamoxifen (considered first-line along with prednisone) 2
  • Colchicine (anti-inflammatory agent) 4

Special Considerations

• If AAT deficiency is identified:
  • Augmentation therapy with purified human AAT or fresh frozen plasma is the treatment of choice
  • Note: Corticosteroids, antibiotics, and cytostatic drugs are ineffective in AAT deficiency-associated panniculitis 3
  • Dapsone alone or combined with augmentation therapy may be considered for less severe cases 3

Surgical Management

• Surgery is generally reserved for:
  • Cases of recurrent bowel obstruction 2
  • Patients who don't respond to medical therapy 4
  • Emergency situations mimicking bowel obstruction or ischemia 5

Monitoring and Follow-up

• Assess for new lesions and healing of existing lesions every 1-2 weeks during initial treatment 3
• Monitor for steroid-related adverse effects:
  • Blood pressure
  • Blood glucose
  • Weight changes
  • Mood alterations
  • Signs of infection 3
• Follow-up imaging to assess treatment response

Common Pitfalls to Avoid

1. Misdiagnosis: Mesenteric panniculitis can mimic other conditions including lymphoma, requiring careful radiological assessment 2
2. Overlooking AAT deficiency: Failure to test for AAT deficiency can lead to inappropriate treatment 3
3. Unnecessary surgery: Due to its benign nature, treatment should be guided by symptom severity and presence of complications, with surgery reserved for specific indications 2
4. Inadequate steroid tapering: Too rapid tapering may lead to symptom recurrence

Prognosis

Overall prognosis is generally good, and recurrence appears to be rare with appropriate treatment 1. Most patients respond well to medical management, with surgical intervention rarely required 4.