Treatment of Sclerosing Mesenteritis
For symptomatic sclerosing mesenteritis, initiate combination therapy with tamoxifen 10 mg twice daily plus prednisone 40 mg daily as first-line treatment. 1, 2
Treatment Algorithm Based on Clinical Presentation
Asymptomatic Patients
- No treatment is required for patients discovered incidentally on imaging without symptoms 2
- Approximately 52% of patients in clinical series received no treatment and had acceptable outcomes 1
Symptomatic Patients Requiring Medical Therapy
First-line therapy:
- Tamoxifen 10 mg twice daily PLUS prednisone 40 mg daily 1, 2
- This combination showed 60% response rate in clinical series, significantly superior to non-tamoxifen regimens (8% response) 1
- 38% of patients responded to medical therapy alone without requiring surgery 1
Alternative approaches if first-line fails:
- Consider other immunosuppressive agents, though evidence is limited 3
- High-dose corticosteroids alone may be considered in patients with autoimmune associations 3
Surgical Intervention
Surgery is reserved for specific complications:
- Persistent bowel obstruction refractory to medical management 2
- Small bowel volvulus secondary to mesenteric involvement 3
- Only 10% responded to surgery alone; 20% required additional medical therapy post-operatively 1
- Surgical approach is often limited due to extensive mesenteric involvement 4
Key Clinical Considerations
Diagnostic confirmation:
- CT imaging is now preferred over biopsy for diagnosis given characteristic findings (mesenteric fat stranding, lymph nodes, haziness at mesentery root) 5, 2
- Biopsy should be reserved for equivocal cases or when malignancy (lymphoma, carcinoid, desmoid tumor, carcinomatosis) cannot be excluded 2
Disease monitoring:
- Long-term follow-up is essential as the disease can have a prolonged, debilitating course 1
- 17% of deaths in one series were attributed to complications of sclerosing mesenteritis or its treatment 1
- Watch for complications including bowel obstruction, chylous ascites, and mesenteric vessel thrombosis 2
Associated conditions to evaluate:
- Screen for autoimmune disorders (antiphospholipid syndrome has been reported) 3
- Consider malignancy surveillance, as associations with lymphoma, melanoma, and other cancers have been reported, though controversial 5
- History of prior abdominal surgery or trauma increases risk 4, 2
Common Pitfalls
- Do not mistake symptoms for irritable bowel syndrome - abdominal pain, bloating, and altered bowel habits can delay diagnosis 5
- Do not use non-tamoxifen regimens as first-line - they have markedly inferior response rates (8% vs 60%) 1
- Do not rush to surgery - medical management should be attempted first, as surgical options are often limited and outcomes inferior to medical therapy 1, 4