Treatment of Mesenteric Panniculitis in Middle-Aged Adults
Most patients with mesenteric panniculitis are asymptomatic and require no treatment, with observation being the appropriate management strategy. 1, 2
Initial Assessment and Diagnosis
Mesenteric panniculitis is a benign chronic inflammatory condition affecting mesenteric adipose tissue, most commonly detected incidentally on abdominal CT imaging. 1, 2 The condition predominantly affects middle-aged to older adults with a male predominance. 3
Key diagnostic features on CT include:
- Mass-like area of increased fat attenuation in the small bowel mesentery, typically in the left upper quadrant 2
- Envelopment of mesenteric vessels with displacement of adjacent bowel 2
- Lymph nodes frequently present within the abnormal mesenteric area 2
Critical differential diagnosis: Malignant lymphoma must be excluded, as it can appear similar on imaging. 2, 3 Consider PET/CT if there is suspicion of underlying malignancy. 2
Treatment Algorithm Based on Symptom Severity
Asymptomatic Patients (Approximately 50% of Cases)
No treatment is necessary for asymptomatic patients discovered incidentally on imaging. 1, 2 These patients require only observation, as mesenteric panniculitis is a benign condition with potential for spontaneous regression. 4
Symptomatic Patients
When symptoms are present (abdominal pain, bloating, diarrhea, constipation, fever, weight loss), treatment decisions should be guided by symptom severity and presence of complications. 2
First-line medical therapy:
- Prednisone (glucocorticoids) is the primary treatment for symptomatic patients, with good responses reported in prolonged treatment courses 1, 4, 2
- Tamoxifen is recommended as first-line therapy alongside or as an alternative to corticosteroids 2, 3
Second-line and novel therapies (for refractory cases):
- Thalidomide has been prospectively evaluated and may be considered 4
- Low-dose naltrexone has been prospectively evaluated as an option 4
- Immunomodulatory and hormonal therapies have been used based on small case series, though significant side effects must be considered 4
Surgical Intervention
Surgery is not curative and should be avoided except for specific complications. 4, 2 Surgical resection is often limited and should only be considered for:
- Relief of focal bowel obstruction secondary to fibrotic forms of the disease 4
- Recurrent bowel obstruction unresponsive to medical management 2
Important caveat: In the absence of severe intestinal obstruction, surgical treatment should not be considered. 1
Clinical Pitfalls and Monitoring
Common pitfall: Overtreatment of asymptomatic disease. Remember that up to half of patients are asymptomatic and the condition is benign with potential for spontaneous regression. 4, 2
Association with malignancy: While some studies suggest mesenteric panniculitis may be a paraneoplastic phenomenon or associated with lymphoma, recent case-control studies indicate it is more likely an independent, non-specific, benign age-related phenomenon. 3 However, maintain vigilance for concurrent malignancy, particularly lymphoma. 3
Duration of symptoms matters: Patients with short duration of symptoms may experience spontaneous regression, while those with prolonged symptoms (chronic pain, fever, altered bowel habits) may require extended corticosteroid therapy. 4