What is the treatment for mesenteric panniculitis?

Treatment for Mesenteric Panniculitis

First-line treatment for symptomatic mesenteric panniculitis is corticosteroids, specifically prednisone, which has shown good clinical and radiological responses during follow-up. 1

Understanding Mesenteric Panniculitis

Mesenteric panniculitis (MP) is a benign condition characterized by chronic inflammation and fibrosis of adipose tissue, primarily affecting the small bowel mesentery. It is often detected incidentally on abdominal imaging and can be asymptomatic in up to nearly half of patients 2.

Clinical Presentation

• Most common symptom: Abdominal pain
• Other symptoms: Bloating/distention, diarrhea, constipation, vomiting, anorexia, weight loss, fever, malaise, and nausea 2
• Radiological findings: Mass-like area of increased fat attenuation within the small bowel mesentery, usually in the left upper quadrant, enveloping mesenteric vessels and displacing adjacent bowel segments 2

Treatment Algorithm

1. Asymptomatic Patients

• Observation without specific treatment is recommended
• Regular follow-up to monitor for development of symptoms or complications

2. Symptomatic Patients

Medical Management (First-line):

• Corticosteroids: Prednisone (dosing typically starts at 40 mg daily with gradual taper based on clinical response) 1, 3
• Second-line options:
  • Tamoxifen (often used in combination with prednisone) 2
  • Azathioprine (immunosuppressive agent) 1
  • Colchicine (anti-inflammatory agent) 1

3. Refractory Cases

• Combination therapy with multiple agents may be considered
• In a study of 40 patients, combination therapy with prednisone, azathioprine, and colchicine was used successfully in some cases 1

4. Surgical Management

• Reserved for cases with complications such as:
  • Recurrent bowel obstruction 2
  • Intestinal stenosis leading to ileus 3
  • When diagnosis is uncertain and malignancy needs to be excluded

Treatment Efficacy

• In a ten-year study of 40 patients, those treated with prednisone showed good responses both clinically and radiologically during follow-up 1
• Only one patient in this study required surgical intervention after failing medical therapy 1
• A case report demonstrated effective treatment of MP-induced ileus with prednisolone in a patient with Sjögren's syndrome 3

Important Considerations

Differential Diagnosis

• Lymphoma is one of the most common differential diagnoses
• Positron emission tomography/computed tomography (PET/CT) may be necessary if there is suspicion of underlying malignancy 2

Monitoring

• Regular clinical follow-up to assess symptom improvement
• Follow-up imaging to evaluate radiological response to treatment
• Monitor for side effects of medications, particularly with long-term corticosteroid use

Pitfalls to Avoid

1. Overly aggressive surgical intervention for what is primarily a medical condition
2. Failure to exclude malignancy, particularly lymphoma, before initiating treatment
3. Inadequate duration of corticosteroid therapy or too rapid tapering
4. Not considering combination therapy in refractory cases

Remember that treatment decisions should be guided by the severity of symptoms and presence of complications, given the benign nature of MP 2.