What is the best approach to manage mesenteric panniculitis in a middle-aged or older adult patient presenting with abdominal pain or bowel obstruction?

Management of Mesenteric Panniculitis

Most patients with mesenteric panniculitis require no treatment if asymptomatic, but those with significant abdominal pain or bowel obstruction should receive prednisone as first-line therapy, with surgery reserved only for recurrent bowel obstruction unresponsive to medical management.

Initial Assessment and Risk Stratification

Asymptomatic patients discovered incidentally on CT imaging require observation only, as mesenteric panniculitis is a benign, self-limited condition in nearly half of cases 1, 2. The disease predominantly affects the small bowel mesentery and presents as chronic inflammation and fibrosis of mesenteric adipose tissue 3, 1.

For symptomatic patients, the severity dictates management:

• Mild symptoms (vague abdominal discomfort, bloating): Conservative management with observation 2
• Moderate symptoms (persistent abdominal pain, distention, diarrhea, constipation): Medical therapy indicated 2, 4
• Severe presentation (bowel obstruction, ischemia): Emergency surgical evaluation required 5

Medical Management Algorithm

First-Line Therapy

Prednisone is the primary medical treatment for symptomatic mesenteric panniculitis, showing good clinical and radiological response during follow-up 4. The typical approach involves:

• Prednisone as monotherapy for patients with moderate symptoms 2, 4
• Tamoxifen can be used as first-line therapy alongside or instead of prednisone 2

Second-Line and Combination Therapy

For patients with inadequate response to prednisone alone or requiring steroid-sparing agents:

• Azathioprine as a steroid-sparing immunomodulator 4
• Colchicine as an alternative anti-inflammatory agent 4
• Combination therapy with prednisone plus azathioprine or colchicine for refractory cases 4

The evidence base for these treatments remains limited, as management is empirical and based on small case series rather than controlled trials 3.

Surgical Indications

Surgery should be avoided in mesenteric panniculitis except for specific complications 1. The surgical approach is often technically limited due to the diffuse nature of mesenteric involvement 3.

Absolute Indications for Surgery:

• Recurrent bowel obstruction unresponsive to medical therapy 2
• Acute bowel obstruction or ischemia requiring emergency intervention 5
• Diagnostic uncertainty when imaging cannot exclude lymphoma or other malignancy requiring tissue diagnosis 2

Surgical Approach When Required:

• Partial bowel resection (jejunal or involved segment) is the typical procedure 5
• Complete resection of all affected mesentery is usually not feasible 3
• Emergency surgery may be necessary when clinical presentation mimics acute obstruction or ischemia 5

Diagnostic Confirmation

CT imaging with IV contrast is the primary diagnostic modality, showing a mass-like area of increased fat attenuation in the small bowel mesentery (typically left upper quadrant) that envelops mesenteric vessels and displaces bowel 2.

PET/CT should be performed if lymphoma cannot be excluded, as this is the most important differential diagnosis 2. Surgical biopsy is reserved for equivocal cases where imaging cannot definitively distinguish mesenteric panniculitis from malignancy 3, 4.

Follow-Up and Monitoring

Patients on medical therapy require:

• Clinical reassessment to monitor symptom resolution 4
• Repeat CT imaging to document radiological improvement in those treated with prednisone 4
• Long-term observation as the disease has a benign natural history 1

Critical Pitfalls to Avoid

Do not perform surgery for diagnostic purposes alone when CT findings are characteristic of mesenteric panniculitis, as the surgical approach is limited and the disease is benign 3, 1.

Do not initiate medical therapy in asymptomatic patients, as treatment is unnecessary and the disease may resolve spontaneously 1.

Do not delay emergency surgical consultation when patients present with signs of bowel obstruction or ischemia, as these rare complications require urgent intervention 5.

Do not confuse mesenteric panniculitis with lymphoma—obtain PET/CT or biopsy if there is any diagnostic uncertainty, as management differs completely 2.