What is the treatment for mesenteric panniculitis?

Treatment of Mesenteric Panniculitis

Corticosteroids are the first-line medical therapy for symptomatic mesenteric panniculitis, with surgery reserved only for severe complications such as bowel obstruction or when medical management fails. 1

Initial Management Approach

Medical Therapy (First-Line)

Corticosteroids (typically prednisone) should be initiated as primary treatment for symptomatic patients, showing good clinical and radiological responses during follow-up. 1, 2 The American Gastroenterological Association recommends focusing management on symptom control with corticosteroids as the cornerstone of therapy. 1

• Prednisone is the most commonly used agent, with documented success in achieving both clinical improvement and radiological resolution. 2
• Prolonged corticosteroid treatment has demonstrated good responses in patients with chronic mesenteric panniculitis. 3
• Alternative immunomodulatory agents include azathioprine and colchicine, which can be used alone or in combination with corticosteroids. 2

Novel and Alternative Therapies

For patients requiring steroid-sparing options or with refractory disease:

• Thalidomide has been prospectively evaluated and shows promise as an alternative therapy. 3
• Low-dose naltrexone represents another prospectively studied option for chronic cases. 3
• Hormonal and immunomodulatory therapies are utilized based on small case series, though clinicians must weigh significant potential side effects. 3

Nutritional Support

Early and sustained dietetic intervention is essential to optimize nutritional status and prevent malnutrition, particularly in patients with chronic symptoms. 1 The European Society for Clinical Nutrition and Metabolism emphasizes this as a critical component of management. 1

• Pain management requires multidisciplinary collaboration involving pain specialists, palliative care teams, and dietitians for patients with mesenteric fibrosis. 1
• Long-term home parenteral nutrition serves as a valid alternative when surgical risks are prohibitively high. 1

Surgical Intervention

Surgery is NOT curative and should be avoided except in specific circumstances. 3 The surgical approach is often technically limited due to the diffuse nature of the disease. 4

Indications for Surgery

Surgery should only be considered when:

• Bowel obstruction occurs that cannot be managed conservatively. 1, 5
• Medical therapy fails after adequate trial of corticosteroids and alternative agents. 1, 2
• Severe complications develop requiring emergency intervention. 5

Surgical Considerations

• Resection of fibrotic tissue or involved bowel segments may provide symptomatic relief but carries significant risk of short bowel syndrome. 1
• Emergency surgery may be necessary when clinical presentation mimics bowel obstruction or ischemia. 5
• Multidisciplinary team agreement is mandatory before proceeding with surgery, particularly in complex cases. 1
• Only one patient in a recent 10-year series of 40 patients required surgery after failing medical therapy, highlighting the rarity of this need. 2

Monitoring and Surveillance

New or worsening gastrointestinal symptoms mandate investigation to exclude other conditions, including malignancy. 1 The American College of Gastroenterology recommends vigilant monitoring given the association between mesenteric panniculitis and various cancers. 1

• CT imaging with IV contrast remains the primary diagnostic and monitoring modality. 4, 2
• Biopsy confirmation may be needed in equivocal cases to exclude neoplastic disease. 4, 2
• Serial imaging helps assess treatment response and detect disease progression. 2

Important Clinical Pitfalls

• Do not pursue aggressive surgical therapy based solely on imaging findings, as this is a benign condition that typically responds to medical management. 6
• Recognize that spontaneous regression can occur in cases with short symptom duration, so observation may be appropriate in asymptomatic or minimally symptomatic patients. 3
• Consider underlying autoimmune conditions, as personal or family history of autoimmune disease is commonly present. 3
• Evaluate for potential triggers including recent trauma, abdominal surgery, infection, or associated malignancies. 3