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, and chronic fibrosing inflammatory disease affecting the adipose tissue of the mesentery, primarily in the small intestine 2
• The specific etiology remains unknown, though it may be immune-mediated or potentially paraneoplastic 3
• Diagnosis is typically suggested by CT imaging and confirmed by surgical biopsies in equivocal cases 2, 4

Medical Management

First-Line Therapy

• Prednisone/corticosteroids show good clinical and radiological responses during follow-up and should be initiated first 4
• Dosing should be tailored based on symptom severity and patient characteristics 1

Second-Line Therapies

• Immunomodulatory agents such as azathioprine can be added when corticosteroid response is inadequate 4
• Colchicine has shown efficacy either alone or in combination with other therapies 4
• Thalidomide and low-dose naltrexone are the only agents that have been prospectively evaluated for mesenteric panniculitis 3

Supportive Care

• Pain management is essential and requires collaboration between pain specialists, palliative care teams, and gastroenterologists 1
• Early dietetic consultation is crucial to optimize nutritional status and prevent malnutrition 1
• Patients should be monitored for new or worsening GI symptoms which may indicate disease progression or development of complications 1

Surgical Management

• Surgery should be reserved for cases with:
  • Intestinal obstruction 5, 6
  • Failed medical therapy 4
  • Need for definitive diagnosis when imaging is inconclusive 2
• Laparoscopic approach is preferred in stable patients due to lower morbidity 5
• Resection of fibrotic tissue may offer symptomatic relief but carries risk of short bowel syndrome 1, 6

Treatment Algorithm

1. Initial presentation:

   • Confirm diagnosis with CT imaging 2
   • Assess symptom severity 1

2. For mild to moderate symptoms:

   • Begin corticosteroid therapy (prednisone) 4
   • Provide symptomatic pain management 1
   • Monitor response clinically and radiologically 4

3. For inadequate response to corticosteroids:

   • Add immunomodulatory agents (azathioprine, colchicine) 4
   • Consider thalidomide or low-dose naltrexone in refractory cases 3

4. For severe symptoms or complications:

   • Evaluate for surgical intervention if medical therapy fails 4
   • Consider partial bowel resection for localized disease causing obstruction 6, 7
   • Implement long-term home parenteral nutrition if surgical risks are too high 1

Monitoring and Follow-up

• Regular clinical assessment of symptoms 1
• Follow-up CT imaging to evaluate treatment response 4
• Vigilance for potential malignancy development, as mesenteric panniculitis may be associated with underlying cancer 1, 3
• Nutritional status monitoring and support 1

Clinical Pitfalls and Considerations

• Mesenteric panniculitis can mimic other conditions including malignancy, inflammatory bowel disease, and mesenteric ischemia 6
• Surgical intervention is not curative and should be avoided except for specific complications 3
• The condition may spontaneously regress in some patients, while others experience prolonged symptoms requiring long-term management 3
• Patients should be educated about warning signs requiring urgent medical attention (severe pain, vomiting, fever) 5