What is the treatment for mesenteric pancolitis?

Treatment for Mesenteric Panniculitis

Initial Management Approach

For symptomatic mesenteric panniculitis, initiate treatment with oral prednisone as first-line therapy, with tamoxifen as an alternative or adjunctive agent. 1

The treatment strategy for mesenteric panniculitis should be guided by symptom severity and presence of complications, as this is fundamentally a benign inflammatory condition. 1 Nearly half of patients are asymptomatic and discovered incidentally on imaging, requiring no intervention beyond observation. 1

Medical Treatment Algorithm

First-Line Therapy

• Prednisone is the primary medical treatment for symptomatic mesenteric panniculitis, showing good clinical and radiological responses during follow-up. 2
• Typical dosing follows standard corticosteroid protocols, though specific regimens vary based on symptom severity. 2

Second-Line and Combination Therapy

• Tamoxifen serves as either an alternative to prednisone or can be used in combination for refractory cases. 1
• Azathioprine or colchicine may be added for patients requiring steroid-sparing agents or those with inadequate response to monotherapy. 2
• Combination therapy with prednisone plus azathioprine or colchicine has been successfully employed in clinical practice. 2

Refractory Pain Management

• For patients with intractable abdominal pain despite immunosuppressive therapy, consider endoscopic ultrasound-guided celiac plexus block as an adjunctive pain control measure. 3
• This intervention is particularly valuable for the minority of patients who continue to have refractory disease despite trials of multiple immunosuppressive agents. 3

Surgical Intervention

Surgery is reserved exclusively for cases of recurrent bowel obstruction or complications requiring emergency intervention. 1, 4

• Emergency surgery with partial bowel resection may be necessary when mesenteric panniculitis causes mechanical obstruction or ischemia that cannot be differentiated preoperatively from other acute abdominal pathology. 4
• Laparoscopic exploration can be diagnostic when imaging is equivocal, revealing inflamed and edematous mesentery with potential venous ischemia. 5
• One critical caveat: most patients who fail medical therapy still do not require surgery, as the natural history can include spontaneous resolution even in severe, symptomatic cases. 5

Monitoring and Follow-Up

• Serial CT imaging should be performed to assess radiological response to therapy, particularly in patients treated with corticosteroids. 2
• Exclude underlying malignancy (particularly lymphoma) through appropriate imaging including PET/CT if there is clinical suspicion, as this is one of the most important differential diagnoses. 1
• Monitor for associated inflammatory disorders or malignancies, though many cases remain idiopathic despite exhaustive investigation. 5

Key Clinical Pitfalls

• Do not rush to surgery for asymptomatic or mildly symptomatic patients, as the condition is benign and may resolve spontaneously. 5
• Do not overlook malignancy screening, particularly lymphoma, which can present with similar imaging findings. 1
• Do not continue ineffective medical therapy indefinitely without considering alternative immunosuppressive agents or pain management strategies. 3
• Be aware that preoperative diagnosis is challenging, and the condition may mimic bowel obstruction or ischemia, potentially leading to unnecessary emergency surgery. 4