What is the treatment for mesenteric panniculitis?

Treatment for Mesenteric Panniculitis

First-line medical treatment for mesenteric panniculitis consists of prednisone and tamoxifen, with treatment decisions guided by symptom severity and presence of complications. 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 presents with various clinical manifestations:

• Common symptoms: Abdominal pain (most frequent), bloating/distention, diarrhea, constipation, vomiting, anorexia, weight loss, fever, malaise, and nausea 1
• Incidental finding: Up to nearly half of patients are asymptomatic, with MP detected incidentally on abdominal imaging 1
• Diagnosis: Primarily based on CT scan with IV contrast, with biopsies performed in equivocal cases 2

Treatment Algorithm

1. Assess Symptom Severity

• Asymptomatic patients: Observation may be appropriate due to the benign nature of the condition 1
• Symptomatic patients: Treatment should be initiated based on symptom severity 1

2. Medical Management (First-Line)

• Corticosteroids: Prednisone is the cornerstone of therapy

  • Patients on prednisone show good responses both clinically and radiologically during follow-up 2
  • Prolonged corticosteroid treatment has shown good responses for chronic MP 3

• Hormonal therapy: Tamoxifen is recommended as part of first-line treatment 1

3. Alternative/Additional Medical Options

• Immunomodulators: Azathioprine can be used alone or in combination with other medications 2
• Anti-inflammatory agents: Colchicine has shown efficacy 2
• Novel therapies:
  • Thalidomide and low-dose naltrexone are the only treatments that have been prospectively evaluated 3
  • These may be considered for refractory cases

4. Surgical Management

• Reserved for specific cases: Surgery is indicated only for cases of recurrent bowel obstruction 1
• Limited role: Surgical intervention is not curative and should be avoided except for relief of focal bowel obstruction secondary to fibrotic forms of the disease 3
• Surgical biopsies: May be necessary for definitive diagnosis in equivocal cases 4

Monitoring and Follow-up

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

Important Considerations

• Differential diagnosis: One of the most common differential diagnoses is lymphoma; PET/CT may be performed if there is suspicion of concurrent underlying malignancy 1
• Associated conditions: MP has been associated with autoimmune diseases, and patients often have personal or family history of other autoimmune conditions 3
• Potential triggers: Trauma, abdominal surgery, infection, and various cancers have been associated with mesenteric panniculitis 3

Cautions and Pitfalls

• Misdiagnosis risk: MP can mimic malignancy, particularly lymphoma, leading to unnecessary aggressive interventions
• Variable presentation: The clinical course can range from mild and self-limiting to chronic and debilitating 3
• Rare acute presentation: Though uncommon, MP can present acutely with severe abdominal pain requiring prompt intervention 5
• Treatment side effects: Hormonal and immunomodulatory therapies may have significant side effects that need careful monitoring 3

The management approach should be tailored based on symptom severity, with prednisone and tamoxifen forming the backbone of medical therapy for symptomatic patients, while reserving surgery only for cases with mechanical complications like bowel obstruction.