What is the treatment for mesenteric panniculitis?

Treatment of Mesenteric Panniculitis

Corticosteroids are the first-line therapy for symptomatic mesenteric panniculitis, with surgical intervention reserved only for cases with severe complications or when medical therapy fails. 1

Clinical Overview

Mesenteric panniculitis is a rare, benign, chronic fibrosing inflammatory disease that affects the adipose tissue of the mesentery, primarily in the small intestine and occasionally in the colon 2. The specific etiology remains unknown, though it may be associated with:

• Autoimmune processes 3
• Previous abdominal trauma or surgery 3
• Infections 3
• Malignancies (potentially paraneoplastic) 3

Diagnostic Approach

• Diagnosis is typically suggested by CT imaging and confirmed by surgical biopsies in equivocal cases 2
• CT findings include mass-like structure at the root of the mesentery 3
• Histological features include focal fat necrosis, chronic inflammation, and sometimes mesenteric fibrosis 3

Treatment Algorithm

First-Line Medical Management

1. Corticosteroids:

   • Prednisone has shown good clinical and radiological responses during follow-up 4
   • Particularly effective for cases with inflammatory symptoms 1

2. Immunosuppressive agents:

   • Azathioprine may be used alone or in combination with steroids 4
   • Consider for steroid-sparing or maintenance therapy 4

3. Anti-inflammatory agents:

   • Colchicine has been used successfully in managing symptoms 4

Second-Line Medical Therapies

For patients with chronic or refractory mesenteric panniculitis:

• Thalidomide (one of the few agents prospectively evaluated) 3
• Low-dose naltrexone (also prospectively evaluated) 3
• Hormonal and immunomodulatory therapies (based on small case series) 3

Supportive Care

• Pain management with appropriate analgesics 1, 5
• Early and sustained dietetic input to optimize nutritional status 1
• Multidisciplinary approach involving pain specialists and palliative care teams for severe cases 1

Surgical Management

Surgery is not recommended as first-line treatment and is reserved for:

• Cases with severe complications (intestinal obstruction, ischemia) 6, 7
• Patients who fail to respond to medical therapy 4
• Situations requiring definitive diagnosis when malignancy cannot be excluded 1

Surgical approaches may include:

• Resection of fibrotic tissue or involved bowel segments 1
• Laparoscopic approach in stable patients 5

Special Considerations

• Surgical resection carries the risk of short bowel syndrome and is not curative 1, 3
• Long-term home parenteral nutrition may be needed if surgical risks are high 1
• New or worsening GI symptoms should prompt investigation to exclude malignancy 1
• Spontaneous regression may occur in some cases 3

Follow-up and Monitoring

• Regular clinical assessment of symptoms 1
• Follow-up imaging to evaluate treatment response 4
• Monitoring for potential side effects of immunosuppressive therapy 3
• Education about warning signs requiring urgent medical attention (severe pain, vomiting, fever) 5

Treatment Pitfalls to Avoid

• Unnecessary aggressive surgical intervention when medical management would suffice 7
• Failure to exclude malignancy before attributing symptoms solely to mesenteric panniculitis 1
• Inadequate nutritional support during treatment 1
• Overlooking the potential for spontaneous regression in milder cases 3