What is the management approach for mesenteric panniculitis?

Management of Mesenteric Panniculitis

The management of mesenteric panniculitis should be guided by symptom severity, with first-line treatment consisting of prednisone and tamoxifen for symptomatic cases, while asymptomatic patients can be monitored without specific intervention. 1

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 diagnosis is typically made through:

• Imaging findings: CT scan is the primary diagnostic tool, showing:

  • Mass-like area of increased fat attenuation within small bowel mesentery
  • Mesenteric vessels enveloped by the inflammatory mass
  • Displacement of adjacent bowel segments
  • Presence of lymph nodes within the area of mesenteric abnormality 1

• Clinical presentation:

  • Up to 50% of patients are asymptomatic (incidental finding on imaging)
  • Common symptoms include:
    • Abdominal pain (most frequent)
    • Bloating/distention
    • Altered bowel habits (diarrhea or constipation)
    • Nausea and vomiting
    • Constitutional symptoms (weight loss, fever, malaise) 1, 2

Treatment Algorithm

1. Asymptomatic Patients

• Observation without specific treatment
• Regular follow-up to monitor for development of symptoms or complications 1

2. Symptomatic Patients

• First-line medical therapy:

  • Prednisone (corticosteroids): Most effective for acute inflammatory symptoms
  • Tamoxifen: Often used in combination with prednisone 1, 2

• Alternative/adjunctive medications:

  • Azathioprine: Immunosuppressant for steroid-sparing effect
  • Colchicine: Anti-inflammatory agent that may help reduce fibrosis 2

3. Refractory Cases

• Combination therapy with multiple agents may be considered
• Patients on prednisolone have shown good responses both clinically and radiologically during follow-up 2

4. Surgical Intervention

• Reserved for:
  • Recurrent bowel obstruction
  • Cases not responding to medical therapy
  • When definitive diagnosis is needed to rule out malignancy 1, 2

Important Considerations

Differential Diagnosis

• Lymphoma: One of the most important differential diagnoses
  • PET/CT may be needed if malignancy is suspected 1
• Crohn's disease: Can mimic MP and should be excluded 3
• Other malignancies: MP has been associated with various malignancies 4

Diagnostic Pitfalls

• Before diagnosing idiopathic MP, it's crucial to exclude:
  • Inflammatory bowel disease (check fecal calprotectin)
  • Malignancy (especially lymphoma)
  • Systemic inflammatory conditions 3

Follow-up

• Regular clinical and radiological follow-up is recommended for all patients
• For those on medical therapy, monitor for:
  • Symptom improvement
  • Radiological changes in the mesenteric mass
  • Medication side effects 2

Special Considerations

• The relationship between MP and malignancy remains complex and controversial

• Some studies suggest an association with lymphomas and other malignancies

• Thorough evaluation to rule out underlying malignancy should be considered, especially in patients with concerning features (significant weight loss, lymphadenopathy) 4

• In cases of diagnostic uncertainty, surgical biopsy may be necessary to confirm the diagnosis and exclude malignancy 5

• The natural history of MP is variable, with some cases resolving spontaneously, others remaining stable, and some progressing despite therapy 5, 2