Mesenteric Panniculitis: Definition and Treatment Approach
Mesenteric panniculitis is a rare, benign chronic inflammatory disease of mesenteric adipose tissue that typically does not require treatment in asymptomatic patients, but symptomatic cases should be treated with glucocorticoids (prednisone) as first-line therapy. 1, 2
What is Mesenteric Panniculitis?
Mesenteric panniculitis (MP) is a rare benign condition characterized by chronic inflammation and fibrosis of the adipose tissue of the mesentery, primarily affecting the small bowel mesentery but occasionally involving the mesocolon and mesosigmoid. 1, 2, 3 The specific etiology remains unknown, though it has been associated with abdominal trauma, prior surgery, and inflammatory bowel disease. 1, 4, 5
Key pathological features:
- Chronic non-specific inflammatory process with fibrosis of mesenteric fat tissue 6
- Presents as a mass-like area of increased fat attenuation on imaging that envelops mesenteric vessels and displaces adjacent bowel 2
- Incidence is extremely low at 0.09-0.2% of acute admissions 7
Clinical Presentation
Most patients (up to nearly 50%) are completely asymptomatic and diagnosed incidentally on abdominal imaging. 2
When symptomatic, the most common manifestations include:
- Abdominal pain (most frequent symptom) 1, 2
- Bloating/distention, diarrhea, constipation 2
- Nausea, vomiting, anorexia, weight loss 2, 3
- Fever and malaise 2
- Palpable abdominal mass in severe cases 3
- Rarely, bowel obstruction or ischemic colitis 3, 6
Diagnosis
CT imaging is the primary diagnostic modality, showing a mass-like area of increased fat attenuation within the small bowel mesentery, typically in the left upper quadrant, with lymph nodes frequently visible within the abnormal area. 1, 2
Histological confirmation through surgical biopsy is often required to definitively diagnose MP and exclude malignancy, particularly lymphoma which is a key differential diagnosis. 1, 4, 3
Treatment Recommendations
Asymptomatic Patients
No medical treatment is necessary for asymptomatic patients. 1 The disease has a benign natural history, and spontaneous resolution can occur even in severe cases. 3
Symptomatic Patients
First-line medical therapy consists of:
- Prednisone (glucocorticoids) - effective for symptomatic relief 1, 2
- Tamoxifen - can be used as first-line therapy alongside or instead of prednisone 2
Treatment decisions should be guided by symptom severity and presence of complications. 2
Surgical Intervention
Surgery should be reserved exclusively for cases with recurrent bowel obstruction or severe intestinal complications. 2, 6 In the absence of severe intestinal obstruction, surgical treatment should not be considered. 1 When required, partial bowel resection may be necessary, though the surgical approach is often limited due to the diffuse nature of the disease. 4, 6
Prognosis
The overall prognosis is excellent with supportive treatment alone. 3 MP is fundamentally a benign disease with good outcomes, and even severe symptomatic cases can resolve spontaneously without therapeutic intervention beyond supportive care. 3
Common pitfalls to avoid: