From the Guidelines
Mesenteric adenitis in a 17-year-old presenting with lower abdominal pain, nausea, and scrotal pain typically requires supportive care while the condition resolves spontaneously. Treatment includes pain management with acetaminophen (650-1000mg every 6 hours) or ibuprofen (400-600mg every 6-8 hours), adequate hydration, and rest. The etiology is usually viral, commonly adenovirus, rotavirus, or enteroviruses, though bacterial causes like Yersinia enterocolitica can occur. In this adolescent, the scrotal pain suggests possible referred pain from inflamed mesenteric lymph nodes. Diagnosis is typically confirmed by CT showing enlarged mesenteric lymph nodes (>5mm) without appendicitis, as recommended by the ACR Appropriateness Criteria for radiologic management of mesenteric ischemia 1. While treatment is supportive, patients should be monitored for worsening symptoms that might indicate complications or alternative diagnoses. Antibiotics are generally not indicated unless bacterial infection is strongly suspected, as stated in the guidelines for acute mesenteric ischemia by the World Society of Emergency Surgery 1. The condition typically resolves within 1-4 weeks as the underlying infection clears. Patients should follow up if symptoms worsen or fail to improve within a week, as this could indicate an alternative diagnosis requiring different management, such as mesenteric ischemia, which has a high mortality rate if left untreated 1. Key points to consider in management include:
- Pain management with acetaminophen or ibuprofen
- Adequate hydration and rest
- Monitoring for worsening symptoms
- Avoidance of antibiotics unless bacterial infection is suspected
- Follow-up if symptoms worsen or fail to improve within a week. It is essential to prioritize the patient's quality of life and minimize morbidity and mortality by providing supportive care and monitoring for potential complications, as supported by the latest guidelines and research 1.
From the Research
Etiologies of Mesenteric Adenitis
- Mesenteric adenitis is a self-limiting inflammatory condition affecting the mesenteric lymph nodes, whose presentation mimics appendicitis or intussusception 2.
- The condition typically occurs in children, adolescents, and young adults 2.
- Clinical and laboratory characteristics are similar in children with symptoms persisting for 2 weeks or less and in those with symptoms persisting for 3-10 weeks 3.
Treatment of Mesenteric Adenitis
- Supportive care including hydration and pain medication is advised for patients with mesenteric adenitis 2.
- It is crucial to reassure patients and families by explaining the condition and stating that affected patients recover completely without residuals within 2-4 weeks, although symptoms may persist for 3 to 10 weeks in half of the patients 2, 3.
- Point-of-care ultrasound (POCUS) can identify mesenteric adenitis in pediatric patients with nonsurgical abdominal pain, and its use may help ED clinicians identify a common cause of nonsurgical abdominal pain in children 4.
Diagnosis of Mesenteric Adenitis
- Ultrasonography is the mainstay of diagnosis, disclosing 3 or more mesenteric lymph nodes with a short-axis diameter of 8 mm or more without any identifiable underlying inflammatory process 2.
- POCUS can identify mesenteric adenitis, typically a diagnosis of exclusion, in pediatric patients with nonsurgical abdominal pain, both by novice and experienced physician-sonologists 4.
- Interobserver agreement between experienced and novice physician sonologists is high, with Cohen κ values of 0.83 and 0.76, respectively 4.
Clinical Characteristics
- The most common indications for POCUS in patients with mesenteric adenitis are suspected appendicitis, suspected intussusception, or undifferentiated abdominal pain 4.
- Patients with mesenteric adenitis may present with symptoms such as abdominal pain, nausea, and vomiting, similar to other conditions like appendicitis 5.
- A diagnosis of appendicitis should be considered in any patient with any two of the following signs or symptoms: vomiting, guarding, tenderness, or right lower quadrant pain 5.