What is the management approach for mesenteric panniculitis?

Management of Mesenteric Panniculitis

Treatment for mesenteric panniculitis should be guided by symptom severity, with first-line medical therapy consisting of prednisone and tamoxifen for symptomatic patients, while asymptomatic patients generally require observation only. 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. Key features include:

• Often detected incidentally on abdominal imaging
• Asymptomatic in up to 50% of patients
• When symptomatic, most commonly presents with abdominal pain, followed by bloating, diarrhea, constipation, vomiting, anorexia, weight loss, fever, malaise, and nausea 1

Diagnostic Approach

Diagnosis is typically made through:

• CT scan with IV contrast showing mass-like area of increased fat attenuation within small bowel mesentery
• Characteristic "misty mesentery" appearance with fat halo sign
• Biopsies in equivocal cases, especially to rule out malignancy 1, 2
• PET/CT may be considered if there's suspicion of underlying malignancy (particularly lymphoma) 1

Treatment Algorithm

1. Asymptomatic Patients

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

2. Symptomatic Patients

• First-line medical therapy:

  • Prednisone (corticosteroids) - most effective for reducing inflammation 2
  • Tamoxifen - often used in combination with prednisone 1

• Second-line options (for steroid-sparing or refractory cases):

  • Azathioprine
  • Colchicine
  • Combination therapy 2

3. Complicated Cases

• Surgical intervention reserved for:
  • Recurrent bowel obstruction
  • Cases not responding to medical therapy
  • When definitive diagnosis is needed to rule out malignancy 1, 3

Monitoring and Follow-up

• Clinical response assessment
• Radiological follow-up to evaluate treatment response
• Monitor for medication side effects, particularly with long-term steroid use
• Surveillance for potential associated malignancies, as MP has been reported to have association with malignancies, especially lymphomas 4

Special Considerations

• Surgical approach is limited and generally avoided unless absolutely necessary 5
• Emergency surgery may be required in cases mimicking bowel obstruction or ischemia 3
• The relationship between MP and malignancy remains complex, requiring holistic evaluation 4

Treatment Efficacy

Studies have shown good clinical and radiological response to prednisone therapy during follow-up, with only rare cases requiring surgical intervention due to failure of medical management 2.