What is the management and treatment approach for mesenteric panniculitis?

Management and Treatment of Mesenteric Panniculitis

The management of mesenteric panniculitis should focus on symptom control with corticosteroids as first-line therapy, while surgical intervention should be reserved for cases with severe complications or when medical therapy fails. 1

Clinical Presentation and Diagnosis

• Mesenteric panniculitis (MP) is a benign condition characterized by chronic inflammation and fibrosis of adipose tissue, primarily affecting the small bowel mesentery 2
• Common symptoms include abdominal pain, bloating/distention, diarrhea, constipation, vomiting, anorexia, weight loss, fever, malaise, and nausea, though up to half of patients may be asymptomatic 2
• Diagnosis is typically made by CT scan showing a mass-like area of increased fat attenuation within the small bowel mesentery, usually in the left upper quadrant, with envelopment of mesenteric vessels and displacement of adjacent bowel segments 2
• Lymphoma is an important differential diagnosis, and PET/CT may be necessary if there's suspicion of underlying malignancy 2

Treatment Algorithm

First-Line Medical Management

• Corticosteroids (prednisone) are the first-line treatment for symptomatic mesenteric panniculitis 2, 3
• Tamoxifen is often used in combination with prednisone as part of first-line therapy 2
• Patients on prednisolone typically show good responses both clinically and radiologically during follow-up 3

Second-Line Options

• Immunomodulatory agents such as azathioprine or colchicine may be used when corticosteroids are contraindicated or ineffective 3, 4
• Thalidomide and low-dose naltrexone have been prospectively evaluated for treatment of chronic MP 4
• Hormonal therapies have been used based on small case series but may have significant side effects 4

Surgical Management

• Surgery is reserved for cases of recurrent bowel obstruction or when medical therapy fails 2, 5
• Surgical intervention is not curative and should be avoided except for relief of focal bowel obstruction secondary to fibrotic forms of the disease 4
• In cases requiring emergency surgery, partial bowel resection may be necessary 5

Special Considerations

Mesenteric Fibrosis Management

• Abdominal pain in mesenteric fibrosis requires close collaboration between pain specialists, palliative care teams, and dietitians 1
• Early and sustained dietetic input is essential to optimize nutritional status and prevent malnutrition 1
• Resection of fibrotic tissue or involved bowel segments may offer symptomatic relief but carries the risk of short bowel syndrome 1
• Despite stage IV disease (if associated with malignancy), surgery may be an option but must be agreed upon in a multidisciplinary team meeting 1
• Long-term home parenteral nutrition is a valid alternative to surgery if surgical risks are considered too high 1

Monitoring and Follow-up

• Regular clinical and radiological follow-up is recommended to assess treatment response 3
• Patients should be monitored for potential complications including bowel obstruction, ischemia, or progression of fibrosis 5
• New or worsening GI symptoms should prompt investigation to exclude other conditions, including malignancy 1

Pitfalls and Caveats

• MP can mimic more serious conditions like bowel obstruction or ischemia, making preoperative diagnosis challenging 5
• Treatment should be guided by symptom severity and presence of complications rather than incidental imaging findings 2
• The relationship between MP and malignancy remains controversial; some studies suggest an association, necessitating appropriate cancer screening 2, 4
• Corticosteroids may provide symptomatic relief but carry risks with long-term use; careful monitoring for side effects is essential 3, 4