A pilot study of thalidomide for patients with symptomatic mesenteric panniculitis

Sclerosing Mesenteritis: A Concise Clinical Review for Clinicians

Sclerosing mesenteritis (SM), an idiopathic nonneoplastic condition affecting 0.18% to 3.14% of the population, is characterized by chronic fat necrosis, inflammation, and fibrosis most commonly of the mesentery of the small intestine. Sclerosing mesenteritis typically presents in the fifth or sixth decade of life, where patients with a history of abdominal surgery and/or autoimmune disease may be at higher risk. While many patients are asymptomatic, clinical features and complications are related to the mass effect resulting from the inflammation and fibrosis involved in the pathogenesis of SM. When present, common signs, symptoms, and complications include abdominal pain, weight loss, diarrhea, palpable abdominal mass on examination, bowel obstruction, chylous ascites, and mesenteric vessel thrombosis. Although SM was historically diagnosed predominantly by biopsy, current practice has shifted away from this to computed tomography imaging of the abdomen, given the invasive nature of biopsy. However, certain conditions, including mesenteric neoplasia (lymphoma, metastatic carcinoid tumor, desmoid tumor, mesenteric carcinomatosis), can mimic SM on imaging, and if clinical suspicion is equivocal, a biopsy may be warranted for definitive diagnosis. Asymptomatic patients do not require treatment. For patients with pronounced symptoms or complicated SM, the combination of tamoxifen 10 mg twice daily and prednisone 40 mg daily is the first-line pharmacotherapy; no randomized controlled trial of this regimen has been performed. Rarely, surgery may be necessary in cases of persistent bowel obstruction refractory to medical management. Sclerosing mesenteritis has an overall benign course in most cases, but disease progression and fatal outcomes have been reported.

A review of 17 cases of mesenteric panniculitis in Zhengzhou Ninth People's Hospital in China

PURPOSE

Mesenteric panniculitis (MP) represents the uncommon, benign and chronic inflammatory disorder affecting the mesenteric adipose tissues. Its etiology, diagnosis and treatment remain unnoticed. Our report focused on shedding more lights on this condition.

PATIENTS AND METHODS

Seventeen MP patients were identified by searching the electronic medical record system in the Zhengzhou Ninth People's Hospital using the search terms "Mesenteric panniculitis" from October 2015 to March 2023. All cases were diagnosed with MP through computed tomography (CT). Their clinical features and treatments were analyzed.

RESULTS

There were altogether 17 cases enrolled for this analysis. The male to female ratio was 8:9, and the median age at diagnosis was 64 (range: 37-96) years. There were 15 patients (88.2%) showing abdominal pain to varying degrees. The proportions of symptoms of nausea, vomiting and fever were 23.5%, 23.5% and 41.2%, respectively. Neoplastic disease was present in 3 patients (17.6%). Meanwhile, 9 patients (52.9%) had gallstones, 3 (17.6%) had cholecystitis and 1 (5.9%) had gallbladder polyps. Six patients (35.3%) received antibiotics treatment only and 1 (5.9%) received oral antibiotics and prednisone. One patient (5.9%) received antibiotics followed by prednisone treatment, because the symptoms were significantly relieved after antibiotic treatment, while the disease recurred soon after, and the symptoms improved again after prednisone treatment. The abdominal pain in 9 patients (52.9%) was relieved spontaneously. Two patients (11.8%) died, including one due to respiratory failure caused by pneumonia and the other one because of pancreatic cancer with lung and liver metastases.

CONCLUSION

MP is a poorly understood chronic inflammatory disease. Patients often have abdominal pain as the main symptom, accompanied by comorbidities in the gallbladder, and the prognosis is usually good after correct diagnosis and treatment, Therefore, the present report aims to promote the awareness among clinicians of patients with non-classic abdominal symptoms, so as to avoid misdiagnosis or missed diagnosis.

Sclerosing mesenteritis following immune checkpoint inhibitor therapy

PURPOSE

Sclerosing mesenteritis (SM), a fibroinflammatory process of the mesentery, can rarely occur after immune checkpoint inhibitor (ICI) therapy; however, its clinical significance and optimal management are unclear. We aimed to assess the characteristics and disease course of patients who developed SM following ICI therapy at a single tertiary cancer center.

METHODS

We retrospectively identified 12 eligible adult cancer patients between 05/2011 and 05/2022. Patients' clinical data were evaluated and summarized.

RESULTS

The median patient age was 71.5 years. The most common cancer types were gastrointestinal, hematologic, and skin. Eight patients (67%) received anti-PD-1/L1 monotherapy, 2 (17%) received anti-CTLA-4 monotherapy, and 2 (17%) received combination therapy. SM occurred after a median duration of 8.6 months from the first ICI dose. Most patients (75%) were asymptomatic on diagnosis. Three patients (25%) reported abdominal pain, nausea, and fever and received inpatient care and corticosteroid treatment with symptom resolution. No patients experienced SM recurrence after the completion of corticosteroids. Seven patients (58%) experienced resolution of SM on imaging. Seven patients (58%) resumed ICI therapy after the diagnosis of SM.

CONCLUSIONS

SM represents an immune-related adverse event that may occur after initiation of ICI therapy. The clinical significance and optimal management of SM following ICI therapy remains uncertain. While most cases were asymptomatic and did not require active management or ICI termination, medical intervention was needed in select symptomatic cases. Further large-scale studies are needed to clarify the association of SM with ICI therapy.

Mesenteric Panniculitis, Sclerosing Mesenteritis and Mesenteric Lipodystrophy: Descriptive Review of a Rare Condition

Mesenteric panniculitis (MP) is the preferred nomenclature for a continuum of inflammatory diseases of the mesentery. The diagnosis of MP is often based on the appearance of a mass-like structure at the root of the mesentery. Characteristic histology includes focal fat necrosis, chronic inflammation, and sometimes mesenteric fibrosis. At present, robust literature related to diagnosis and management of MP are limited. MP is postulated to be an immune-mediated chronic inflammatory and/or a paraneoplastic disease. A personal or family history of other autoimmune diseases is commonly apparent. Several inciting events have been identified that possibly act as triggers in the development of the disease. Trauma, abdominal surgery, infection, and various cancers have been associated with mesenteric panniculitis. There are several diagnostic and histologic criteria that aid in making the diagnosis of MP. The differential diagnosis for a mesenteric mass includes neoplastic disease, and a biopsy may be indicated to rule out other conditions. While cases of MP with a short duration of symptoms, or spontaneously regression may occur, some patients experience prolonged periods of pain, fever, and alterations in bowel habit, causing significant morbidity. A variety of medical therapies have been suggested for MP. Only two, thalidomide and low-dose naltrexone, have been prospectively evaluated. For patients with chronic MP, good responses to prolonged corticosteroid treatment have been reported. Novel therapies include thalidomide and low-dose naltrexone. Hormonal and immunomodulatory therapies are also used based on small case series, but these treatments may have significant side effects. Surgical intervention is not curative and is avoided except for relief of focal bowel obstruction secondary to fibrotic forms of the disease.

Colchicine as an Alternative First-Line Treatment of Sclerosing Mesenteritis: A Retrospective Study

BACKGROUND

Sclerosing mesenteritis is a rare condition characterized by chronic inflammation and fibrotic changes of the mesentery.

AIMS

To determine the long-term management and outcomes of patients with sclerosing mesenteritis.

METHODS

Patients with biopsy-proven sclerosing mesenteritis at the Mayo Clinic between January 2006 and December 2016 were identified. Clinical data were collected retrospectively.

RESULTS

One hundred and three patients were identified, median age 68.0 years (range 35.0-85.3). Most patients were symptomatic (87.4%) at presentation. Patients received no treatment (52.4%), medical therapy (42.7%) or surgery (4.9%) on initial diagnosis. The most common initial regimens were prednisone plus tamoxifen (41.9%), prednisone alone (23.3%), and prednisone plus colchicine (11.6%) with 55.6%, 57.2%, and 60% of patients improving, respectively, p = 0.85 for a difference in response rates. At least half of the patients responded to prednisone plus tamoxifen, prednisone plus colchicine, or prednisone alone at 6.0, 7.2, and 8.4 months, respectively. At a median follow-up of 45.6 months (95% CI 24.1-69.7), 65.4% of patients were receiving medical therapy. Of those receiving tamoxifen-based, steroid-based, or steroid-sparing regimens, 100%, 87.5%, and 77.8% had improved by their last follow-up appointment respectively, p = 0.15.

CONCLUSION

Prednisone plus colchicine has a similar efficacy to prednisone plus tamoxifen for the initial and long-term treatment of sclerosing mesenteritis. The majority of patients were initiated on medical therapy over the long term with most reporting symptomatic improvement within a year. Death from SM was rare.

Sclerosing Mesenteritis Complicated With Mesenteric Lymphoma Responsive to Ustekinumab

A 45-year-old man with a 10-year history of biopsy-proven, steroid-dependent sclerosing mesenteritis failed/was intolerant to tamoxifen, azathioprine, colchicine, cyclophosphamide, and methotrexate. He developed osteoporosis, diabetes, and bilateral cataracts. He responded to infliximab but was diagnosed with mesenteric large B-cell lymphoma 6 months after treatment initiation. He achieved remission from lymphoma after chemotherapy, but the sclerosing mesenteritis remained poorly controlled. He was treated with ustekinumab (520 mg intravenously followed by 90 mg subcutaneously every 8 weeks), leading to complete steroid-free remission. He remains symptom and cancer-free 24 months after starting ustekinumab.

Debilitating Manifestation of a Disease with Multiple Names: A Severe Case of Sclerosing Mesenteritis

Sclerosing mesenteritis (SM) is a rare inflammatory condition with unknown etiology that affects the mesenteric adipose tissue. We present a case of a 49-year-old male with severe abdominal pain who underwent abdominal biopsy confirming the presence of adipose inflammation and necrosis. The diagnosis of SM was made, and the patient was treated with prednisone and tamoxifen. As this condition is rare, there are no standard guidelines for management. This case aims to outline a possible treatment plan.

Sclerosing Mesenteritis

Sclerosing mesenteritis is a rare non-neoplastic disorder characterized by fat necrosis, chronic inflammation, and fibrosis typically of the small bowel mesentery. Our understanding of this disorder is limited by its rarity as well as inconsistent terminology used across the literature. While prior abdominal surgery or trauma, autoimmunity, infection, ischemia, and malignancy have been suggested to be involved in the pathogenesis of the disorder, it remains poorly understood. The clinical course of sclerosing mesenteritis is generally benign with a large proportion of patients diagnosed incidentally on imaging obtained for other indications. In a subset of patients, symptoms may arise from a mass effect on the bowel, lymphatics, or vasculature resulting in bowel obstruction, chylous ascites, or mesenteric ischemia. Symptomatic patients should be treated with a combination of corticosteroid and tamoxifen as first-line therapy based on retrospective case series and experience in other fibrosing disorders. Surgical intervention may be required in those with persistent obstruction despite conservative treatment, though complete resection of the mass is often not feasible given intimate involvement with the mesenteric vasculature. A careful use of terminology and communication between the radiologist, pathologist, and clinicians in the care of these patients will be essential to future efforts at understanding this disease.

The Mesentery, Systemic Inflammation, and Crohn's Disease

Initially thought to be a structure that only provided support to the abdominal contents, the mesentery has now gained special attention in the scientific community. The new approach of studying the mesentery as an individual organ has highlighted its importance in the development of local and systemic inflammatory diseases and its potential role in Crohn's disease. Its topographical relationship with the intestine in the setting of active inflammation and "creeping fat" is possibly one of the most important arguments for including the mesentery as an important factor in the pathogenesis of Crohn's disease. In this review, we discuss the importance of the mesentery from the anatomical and embryological standpoints. We also will summarize data on mesenteric inflammation in patients with Crohn's disease. The significance of the mesentery in systemic inflammatory syndromes will be discussed, and we provide an overview of primary inflammatory disorders of the mesentery. Finally, we discuss surgical approaches for patients requiring resection for Crohn's disease that incorporate mesenteric factors, pointing out recent data suggesting that these have the potential for improving outcomes and reducing disease recurrence. 10.1093/ibd/izy201_video1izy201.video15794169491001.

Sclerosing mesenteritis: a comprehensive clinical review

Sclerosing mesenteritis is a rare disease entity initially described in 1924 with a prevalence reported to be less than 1%. Sclerosing mesenteritis is a comprehensive term used to describe three almost similar clinical entities including mesenteric panniculitis, retractile mesenteritis, and mesenteric lipodystrophy which only differ by their histology. The etiology of sclerosing mesenteritis is uncertain, but the disease has been associated with trauma, autoimmune disease, surgery, and malignancy. The typical presenting symptom is the abdominal pain, but sclerosing mesenteritis has a broad constellation of presenting symptoms which often makes consideration of the diagnosis unlikely. Treatment for this little-understood disease ranges from surgical intervention for patients presenting with obstructive symptoms to immunosuppressive medical therapy for patients presenting with pain. The purpose of this article is to provide an overview of the literature relevant to the diagnosis, etiology, and management of this condition in hopes of making physicians aware of this unique condition.

Sclerosing mesenteritis in a 5-year-old Chinese boy: a case report

Background

Sclerosing mesenteritis is a rare fibroinflammatory disorder of unknown etiology that primarily affects the mesentery of the small intestine during late adult life. Only about twenty pediatric cases have been reported to date, but none has been reported in Chinese children.

Case presentation

A 5-year-old Chinese male presented with a 4-week history of recurrent bloating, abdominal pain, anorexia and vomiting. On admission, physical examination showed a severely distended abdomen. Biochemical investigations showed a slightly increased C-reactive protein, and normal serum levels of electrolytes and erythrocyte sedimentation rate. An abdominal film showed small intestine obstruction and massive ascites. An exploratory laparotomy revealed widespread inflammatory fibrotic adhesions between the bowel and the abdominal wall, thickening of the small bowel and massive ascites. During a prolonged hospital course, a 2nd surgery (4 months after 1st exploratory laparotomy) was performed in order to close the ileostomy and revealed that the bowel was still severely edematous, with very tight adhesions between the bowel and the abdominal wall. Histopathological examination of excised mesentery and nodules showed chronic inflammatory cell infiltration, fat necrosis and fibrosis. A diagnosis of sclerosing mesenteritis was finally established. Prednisolone at 2 mg/kg was started and he experienced rapid clinical improvement in 4 weeks.

Conclusions

Sclerosing mesenteritis is extremely rare in children and often misdiagnosed due to its nonspecific clinical manifestation. It is important to be aware of sclerosing mesenteritis when evaluating a child with intractable abdominal pain, bloating, intestinal obstruction and massive ascites.

Sclerosing mesenteritis and mesenteric panniculitis - clinical experience and radiological features

BACKGROUND

Sclerosing mesenteritis (SM) is sometimes used as an umbrella-term for idiopathic inflammatory conditions in the mesentery. Mesenteric panniculitis (MP) is a radiological finding and its relation to clinical SM is not fully understood. The aims of this study were to determine whether any correlation could be found between the radiological findings and the clinical disease course.

METHODS

Patients observed due to idiopathic inflammation of the mesentery were identified. If SM could be verified histologically or MP radiologically, the patients were included in this descriptive retro perspective study.

RESULTS

Typical radiological changes were observed in 27 patients. A majority (23/27) of these patients had mild to moderate symptoms. This group with typical radiology was labelled MP. Four patients were included due to histologically verified disease but had uncharacteristic radiology involving multiple compartments of the abdomen. All four had marked systemic inflammation, fever and fluctuating radiologic findings. Three had severe disease with multiple hospitalisations and complications but responded promptly to corticosteroids. This group was denoted SM.

CONCLUSIONS

We have identified two subgroups of patients; firstly, MP with stable and characteristic radiologic changes and secondly SM with atypical radiology and a more aggressive clinical course. We propose that the term SM should be reserved for this latter condition.

Undiagnosed Sjögren's Syndrome Presenting as Mesenteric Panniculitis

Mesenteric panniculitis is a rare inflammatory and fibrotic process that affects the small intestine mesentery. It may occur following abdominal surgery or in association with a variety of conditions, including malignancy, infection, and certain autoimmune and inflammatory conditions. Herein, an unusual case of mesenteric panniculitis in a patient with primary Sjögren's syndrome will be presented. The patient presented with abdominal pain, weight loss, sicca symptoms, fatigue, and arthralgia. An abdominal CT revealed mesenteric fat stranding and prominent lymph nodes of the small intestine mesentery. She was found on laboratory workup to have positive antinuclear and anti-SSa antibodies. Minor salivary gland lip biopsy revealed focal lymphocytic sialadenitis. The patient's symptoms and CT findings improved with corticosteroids. This case suggests that Sjögren's syndrome should be considered as an underlying disease process in the evaluation of patients with mesenteric panniculitis.

[Mesenteric panniculitis]

Mesenteric panniculitis is a condition characterized by chronic nonspecific inflammation of the mesentery. There is little and often confusing information about its characteristics and the approach to take once it has been demonstrated by an imaging test. We propose to describe the epidemiological, clinical, laboratory, radiological and pathological features of the patients with mesenteric panniculitis reported in the literature, as well as possible disorders causal or associated with mesenteric panniculitis, in the opinion of the authors of each study. Finally, we will review the different therapeutic options used and the response to them. To that end a literature search was performed from the main medical databases selecting ítems with information on these aspects. This information was collected on a database stored in SPSS software for further analysis and summary.

Mesenteric Panniculitis in a Thirteen-Year-Old Korean Boy Treated with Prednisolone: A Case Report

Pediatric mesenteric panniculitis is an extremely rare disease of unknown etiology characterized by chronic inflammation, fat necrosis, and fibrosis in the mesenteric adipose tissue. A previously healthy 13-year-old boy was admitted because of right upper abdominal pain. An abdominal computed tomography scan revealed increased attenuation and enhancement in the left upper abdominal omental fat and anterior peritoneal wall thickening. A laparoscopic biopsy showed mesenteric panniculitis with chronic inflammation, adiponecrosis, and septal fibrosis. Serological tests for autoimmune diseases, nested polymerase chain reaction for Mycobacterium tuberculosis, and special immunohistochemical stains for malignancy were all negative. Symptomatic improvement and improved abnormal findings were achieved after an 8-month treatment with prednisolone according to a follow-up abdominal computed tomography scan. Here, we report a case of pediatric mesenteric panniculitis treated with prednisolone.

Mesenteric panniculitis: an update

In 1924, mesenteric panniculitis was first described in the medical literature by Jura et al. as 'retractile mesenteritis.' It represents a spectrum of disease processes characterized by degeneration, inflammation and scarring of the adipose tissue of the mesentery. The clinical presentations vary according to the stage of the disease and they include abdominal pain, weight loss, nausea and vomiting. Computed tomography findings are usually diagnostic. The gross findings include thickening of the mesentery, mass lesions and adhesion to the surrounding organs. Histologically, there is a chronic inflammatory process involving the adipose tissue with fat necrosis, inflammation and fibrosis. Herein, the authors address the clinicopathological features, course, treatment and pathogenetic mechanisms of mesenteric panniculitis.

Mesenteric panniculitis in a child misdiagnosed as appendicular mass: a case report and review of literature

Mesenteric panniculitis is a chronic inflammatory process involving the adipose tissue of the mesentery. The etiology is unknown, and it is rare in children. We report a 5 year old girl who presented with abdominal symptoms and was misdiagnosed as appendicular mass. The correct diagnosis was established after surgical resection.

Refractory sclerosing mesenteritis involving the small intestinal mesentery: a case report and literature review

A 28-year-old Japanese man presented with upper abdominal pain. Computed tomography (CT) revealed a soft tissue mass in the small bowel mesentery. We diagnosed the patient with sclerosing mesenteritis according to the histological findings of small bowel mesentery. Although he was treated with prednisolone, colchicine and azathioprine, neither his symptoms nor CT findings improved. This case is rare in that the disease was refractory. The characteristics of Japanese patients with sclerosing mesenteritis involving small bowel mesentery are not well understood. We herein describe the details of such patients based on a literature review including 32 recently reported Japanese cases.

[Mesenteric panniculitis]

Mesenteric panniculitis is a nonspecific inflammatory process affecting the fatty tissue at the root of the mesentery. This term is also used to describe the clinical and imaging findings in this disorder. Mesenteric panniculitis can be a misleading term: it is commonly misused to design an increased density of the mesentery without prejudice regarding the etiology. Pain is the main clinical symptom. Half of the patients are asymptomatic. There is a palpable mass in half of cases. Laboratory tests sometimes reveal an acute phase reaction of varying intensity. Mesenteric panniculitis is suspected when CT scan shows increased density of the mesenteric fat. Nevertheless, only histological examination could establish the diagnosis. Histologic examination may reveal various stages: lipodystrophy (the first stage when fat necrosis is predominant), mesenteric panniculitis (a majority of infiltrating lymphocytes), sclerosing mesenteritis (the end stage when fibrosis is predominant). Histopathologic differential diagnoses are lymphomas, lipomas, liposarcomas that can mimic mesenteric panniculitis on CT scan. Mesenteric panniculitis is associated with various diseases, especially with intra-abdominal inflammatory process. It also can be idiopathic. Rare complications can occur with vascular or digestive tract compressions. Empirical treatment is only useful in symptomatic patients. Colchicine, corticosteroids or immunosuppressive agents can be used. The only interest of surgery is the histological confirmation of the diagnosis. A better understanding of the pathophysiology of the immunoregulatory functions of adipose tissue will improve mesenteric panniculitis management.

Mesenteric panniculitis presenting with acute non-occlusive colonic ischemia

BACKGROUND

The role of positron emission tomography (PET) of the mesentery as a diagnostic modality in cases of mesenteric panniculitis is unclear.

CASE PRESENTATION

A 67-year-old woman presented with rectal bleeding due to nonocclusive colonic ischemia. Abdominal CT showed features of mesenteric panniculitis. PET-CT demonstrated no abnormal fluorine-18 fluordeoxyglucose uptake in the affected mesentery or any surrounding lymph nodes. Laparoscopic biopsies from a thickened segment of mesenteric fat excluded neoplastic infiltration.

CONCLUSIONS

In cases of unexplained ischemic colitis, panniculitis should be considered a possible diagnosis. PET-CT may be negative for fluorine-18 fluordeoxyglucose uptake in this condition. As of known false-negative PET-CT results in mesenteric panniculitis, PET-CT has a limited role in the diagnostic work-up.

Sclerosing Mesenteritis: Diverse clinical presentations and dissimilar treatment options. A case series and review of the literature

Sclerosing mesenteritis (SM) is a rare pathological condition affecting the mesentery. It is a benign, non-specific inflammation of the adipose tissue of the mesentery of the small intestine and colon. It is characterized by a variable amount of chronic fibrosis. Its etiology is unknown, the pathogenesis is obscure, while the pathological characteristics of the disease are unspecific. The initial clinical presentation varies from typically asymptomatic to that of an acute abdomen. The diagnosis is suggested by computed tomography but is usually confirmed by surgical biopsies. Treatment is largely empirical; it is decided upon on the basis of the clinical condition of the patient, and usually a few specific drugs are used. Surgical resection is sometimes attempted for definitive therapy, although the surgical approach is often limited. We will present five cases of SM as well as a review of the available literature in order to state and compare a variety of clinical presentations, diverse possible etiologies and dissimilar treatment options.

Sclerosing mesenteritis successfully treated with a TNF antagonist

A 29-year-old female presented with intermittent nausea, vomiting, fevers, abdominal pain and fatigue. CT scans of the abdomen revealed inflammatory changes within the mesentery and small bowel. Histopathology of the mesentery and omentum showed chronic inflammation and fibrosis, supporting a diagnosis of sclerosing mesenteritis. Over the past 2 years, the patient suffered debilitating paroxysmal abdominal pain despite treatment with prednisone, azathioprine, sulfasalazine and narcotics. Additionally, she developed sacroiliitis diagnosed clinically and on radiographs. Intravenous infliximab (5 mg/kg intravenous) was initiated and continued every 6 weeks for 3 years. The patient has since had a dramatic improvement in her back and abdominal symptoms and has tapered off of prednisone, azathioprine and narcotics. Erythrocyte sedimentation rate, anaemia, leukocytosis and radiographic findings improved after initiation with infliximab. In conclusion, the authors report successfully treating sclerosing mesenteritis with sacroiliitis by the addition of infliximab. This may implicate a role for tumour necrosis factor α in disease pathogenesis.

Idiopathic sclerosing mesenteritis in paediatrics: Report of a successfully treated case and a review of literature

A 6 year old female with symptoms of small bowel obstruction underwent an exploratory laparotomy which revealed widespread evidence of inflammatory fibrotic adhesions involving the jejunal mesentery. In view of persistent growth failure, chronic anaemia, elevated acute phase reactants and imaging evidence of a diffuse progressive inflammatory process, the child was treated with corticosteroids and methotrexate with complete response. The literature on juvenile idiopathic sclerosing mesenteritis has been reviewed.

Normal Positron Emission Tomography-Computerized Tomogram in a Patient with Apparent Mesenteric Panniculitis: Biopsy Is Still the Answer

Mesenteric panniculitis (also known as sclerosing mesenteritis) is a chronic inflammatory disease of the mesenteric connective tissue. It is known to have a wide spectrum of clinical and radiological presentations. In general, biopsy is recommended for diagnosis; however, a recent study proposed that a negative positron emission tomography- computerized tomography (PET-CT) scan is accurate in differentiating benign and neoplastic mesenteric processes [Br J Radiol 2006;79:37–43]. The following case report questions the accuracy of PET-CT in this setting and confirms the requirement for biopsy to rule out the presence of mesenteric lymphoma.

Sclerosing mesenteritis as a rare cause of abdominal pain and intraabdominal mass: a cases report and review of the literature

Sclerosing mesenteritis is a rare, benign, and chronic fibrosing inflammation disease with unknown etiology that affects the mesentery of small bowel and colon. The disease has two well-established histological types: the acute or subacute form known as mesenteric panniculitis and the chronic form known as retractile or sclerosing mesenteritis. Because the sclerosing mesenteritis is lack of special clinical manifestation and typical signs, so the patients are very easy to be misdiagnosed. The correct diagnosis of sclerosing mesenteritis depends on pathological examination and exploratory laparotomy. We report a case of sclerosing mesenteritis in a 52-year-old male who presented with chronic abdominal pain and intraabdominal mass. This patient had a long-term and heavy drinking history. He was misdiagnosed as celiac teratoma by CT examination and then underwent an exploratory laparotomy at March 2 2004. A mass, its diameter being about 5 cm, was detected in mesentery of distal ileum. Although a few small intestines tightly adhered on the mass, the involved intestine had no obstruction. The intraoperative biopsy indicated that it was an inflammatory mass. The mass and adhered intestines were removed. He was diagnosed with sclerosing mesenteritis by histopathological examination of paraffin section. After operation, this patient went well and lives without recrudescence at the time we wrote this paper.

Sclerosing mesenteritis: clinical features, treatment, and outcome in ninety-two patients

BACKGROUND & AIMS

Sclerosing mesenteritis is a rare non-neoplastic disease that affects the small bowel mesentery with chronic fibrosing inflammation. There are few data on the natural history and therapeutic options for this condition.

METHODS

We performed a retrospective and prospective study to describe the clinical characteristics, therapy, and outcome of all cases of sclerosing mesenteritis diagnosed at the Mayo Clinic, Rochester, from 1982-2005.

RESULTS

Ninety-two cases were identified; 70% were male, with a median age of 65 years (interquartile range, 55-72). Common presenting symptoms included abdominal pain in 70%, diarrhea in 25%, and weight loss in 23%. Treatment included medical therapy alone in 26%, surgery alone in 13%, surgery followed by medical therapy in 9%, and 52% received no treatment. Ten percent responded to surgery alone, 20% responded to additional medical treatment after surgery, and 38% responded to medical therapy alone. Tamoxifen in combination with prednisone was used in 20 patients, and 60% improved. Non-tamoxifen-based regimens were used in 12 patients, and 8% improved. Eighteen deaths were noted during the study period, and 17% were attributed to complications of sclerosing mesenteritis or its treatment.

CONCLUSIONS

Although a relatively benign condition, sclerosing mesenteritis can have a prolonged debilitating course with a fatal outcome. Our results suggest that symptomatic patients might benefit from medical therapy, particularly tamoxifen and prednisone combination treatment. Long-term follow-up is needed to substantiate these results.

Retractile mesenteritis presenting as protein-losing gastroenteropathy

Retractile mesenteritis is a rare, idiopathic condition characterized by nonspecific inflammation of the mesenteric adipose tissue. The majority of patients present with abdominal pain and/or a palpable mass. In the present report, a 68-year-old man with peripheral edema and mild hypoalbuminemia is presented. Protein-losing gastro-enteropathy was confirmed with an abnormal stool alpha1-antitrypsin clearance test and retractile mesenteritis was diagnosed at laparoscopy. This rare condition may respond to therapy with corticosteroids, azathioprine, cyclophosphamide, colchicine, progesterone, tamoxifen or thalidomide. Gastroenterologists should consider the diagnosis of protein-losing enteropathy in patients who present with unexplained peripheral edema or hypoalbuminemia. The test of choice to confirm this diagnosis is the stool alpha1-antitrypsin clearance test.

[Mesenteric panniculitis]

Mesenteric panniculitis also named retractile mesenterite is a rare tumor-like lesion that thickens and shortens the mesentery. It is characterized by the association of inflammation, necrosis or fibrosis involving the adipose tissue of the bowel mesentery. The pathophysiology of this disease remains unclear despite associations with inflammatory diseases or malignancies, especially lymphomas that have been described. When symptomatic, patients may present with abdominal pain, palpable abdominal mass or intestinal obstruction. The disease remains asymptomatic in 30 to 50% of cases. Abdominal CT plays an important role in suggesting the diagnosis and can be useful in distinguishing the several conditions that can mimic mesenteric panniculitis. Nevertheless, pathologic examination of surgical excisional biopsies or sometimes percutaneous biopsies remains necessary to confirm the diagnosis and exclude an underlying infection or malignancy. Medical treatment may consist of therapy with anti inflammatory or immunosuppressive agents and can be proposed in highly symptomatic diseases. Surgical treatment should be exclusively attempted when intestinal obstruction or ischemia occur. Most of the time, it consists in intestinal derivation or segmental resection because complete excision of the lesions is often not possible. Mesenteric panniculitis usually has an uneventful clinical course and resolves spontaneously in a variable delay.

A prospective, randomized, double-blind, placebo-controlled trial of retinol palmitate (vitamin A) for symptomatic chronic radiation proctopathy

PURPOSE

This study was designed to determine whether oral retinol palmitate (vitamin A) can reduce the symptoms of radiation proctopathy.

METHODS

A randomized, double-blind trial comparing retinol palmitate (10,000 IU by mouth for 90 days) to placebo was conducted. Eligible patients were more than six months postpelvic radiotherapy and had significant symptoms as measured with the Radiation Proctopathy System Assessments Scale. Nineteen patients were randomized in total: ten to retinol palmitate and nine to placebo. The Radiation Proctopathy System Assessments Scale scores before and every 30 days for 90 days were measured. Five placebo nonresponders were crossed over to the retinol palmitate for another 90 days. Response was defined as a reduction in two or more symptoms by at least two Radiation Proctopathy System Assessments Scale points.

RESULTS

Seven of ten retinol palmitate patients responded, whereas two of nine responded to placebo (P = 0.057). Mean pre-post-treatment change in Radiation Proctopathy System Assessments Scale (delta Radiation Proctopathy System Assessments Scale) in the retinol palmitate group was 11 +/- 5, whereas delta Radiation Proctopathy System Assessments Scale in the placebo group was 2.5 +/- 3.6 (P = 0.013, Mann-Whitney U test). Additionally, all five placebo nonresponders who were crossed over to treatment with retinal palmitate responded to treatment.

CONCLUSIONS

In our trial, retinol palmitate significantly reduced rectal symptoms of radiation proctopathy, perhaps because of wound-healing effects. The current results can serve as the foundation for future trials examining retinol palmitate in the multi-institutional setting.