Sclerosing mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy: a single entity?

AGA Clinical Practice Update on Sclerosing Mesenteritis: Commentary

DESCRIPTION

The purpose of this American Gastroenterological Association Institute Clinical Practice Update is to review the available evidence for diagnosing and treating, as well as examine opportunities for future research in, sclerosing mesenteritis.

METHODS

This Clinical Practice Update expert commentary was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This expert commentary incorporates important and recently published studies in this field, and it reflects the experiences of the authors who are gastroenterologists with expertise in this topic.

Sclerosing Mesenteritis Presenting as Hilar Cholangiocarcinoma Causing Recurrent Chylous Ascites and Gastric Outlet Obstruction

Sclerosing mesenteritis is a rare spectrum of disease that results in chronic inflammation and fibrosis of the abdominal mesentery. Its heterogeneous presentation, nondiagnostic imaging, and pathology findings make diagnosis challenging. In this study, we present the first reported case of hilar sclerosing mesenteritis resulting in chylous ascites, gastric outlet obstruction, and duodenal perforation. Diagnosis was made after extensive investigations including computed tomography imaging, magnetic resonance cholangiopancreatography, positron emission tomography scan, bidirectional endoscopy, endoscopic ultrasound, and diagnostic laparoscopy. While initially mistaken for hilar cholangiocarcinoma, the patient has significant clinical improvement with corticosteroids and now remains in symptomatic and radiographic remission on low-dose prednisone and tamoxifen.

Mesenteric panniculitis: A case report

INTRODUCTION AND IMPORTANCE

Mesenteric panniculitis is a rare, benign condition characterized by chronic inflammation and fibrosis of mesenteric adipose tissue (Hussein and Abdelwahed, 2015; Gögebakan et al., 2018 [1, 2]). While its etiology remains unclear in many cases, it has been associated with various conditions including abdominal surgery, trauma, and inflammatory diseases (Buragina et al., 2019 [3]). Understanding its presentation and management is crucial for proper patient care.

CASE PRESENTATION

We present a case of mesenteric panniculitis in a 49-year-old woman who presented with significant weight loss. The diagnosis was confirmed through imaging studies and tissue biopsy, with successful symptomatic management through conservative treatment.

CLINICAL DISCUSSION

The condition typically presents with nonspecific symptoms including abdominal pain, nausea, and weight loss, though it may be discovered incidentally. Diagnosis relies on a combination of imaging findings, particularly the characteristic "misty mesentery" appearance on CT scan, and when indicated, histological confirmation.

CONCLUSION

Early recognition and appropriate management of mesenteric panniculitis are essential for optimal outcomes. While usually benign, the condition requires thorough evaluation to exclude underlying malignancy and careful monitoring to prevent complications.

Primary Eosinophilic Panniculitis of the Greater Omentum in a Young Girl: A Case Report

Introduction

Primary (or idiopathic) panniculitis involving the intra-abdominal adipose tissue is rare, and its pathogenesis remains unknown. A case of primary eosinophilic panniculitis that involved the greater omentum of a girl is reported.

Case Presentation

The patient, an 11-year-old girl, complained of dull periumbilical pain and nausea, and radiological examination showed a mass lesion in the abdomino-pelvic cavity. On laparoscopy, a plaque-like, flat mass was seen in the greater omentum, and laparoscopic omental resection was performed. On histopathological examination, the interlobular fibrous septa of omental adipose tissue were widened by inflammatory edema, prominent infiltration of eosinophils, and loose proliferation of myofibroblasts. Dense lymphocytic infiltration was also noted around small veins. Inflammatory changes were mild in the fat lobules, and fat necrosis and infiltration of lipid-laden macrophages were absent. Findings of obliterative phlebitis or arteritis were not seen.

Conclusion

Isolated involvement of the omentum by a panniculitic process is rare, and the pathogenesis of eosinophilic septal panniculitis found in the present case remains unknown, but involvement of a hypersensitivity reaction against some unknown stimuli is presumed, based on the histopathological resemblance of the omental lesions to erythema nodosum or eosinophilic panniculitis of the skin. We should keep in mind the possibility that the omental lesion in this patient is a harbinger of more serious immunological disorders. Careful, long-term follow-up and monitoring of the patient are needed.

Sclerosing Mesenteritis Presenting as Intestinal Occlusion: A Case Report

Sclerosing mesenteritis is a chronic disease that primarily affects the mesenteric adipose tissue and encompasses a range of fibrotic and inflammatory pathologies. Due to its low incidence, the etiology remains unclear, though various factors are thought to contribute to its onset. Clinical manifestations are nonspecific, ranging from asymptomatic cases to persistent abdominal pain, which is the most common symptom. Incidental findings on imaging have increased with the widespread use of computed tomography (CT) scans. However, the diagnosis remains histological. Sclerosing mesenteritis is mainly associated with a good prognosis, as it typically follows a benign clinical course and rarely presents with complications or persistent symptoms. In this article, the authors present a clinical case of an 82-year-old male patient who presented with abdominal pain, constipation, and vomiting. The patient underwent an urgent laparotomy for intestinal occlusion. Histological examination confirmed sclerosing mesenteritis. Due to its limited understanding, sclerosing mesenteritis is often misdiagnosed. It should be considered as a differential diagnosis, particularly in patients with poorly defined abdominal pain, normal laboratory studies, and nonspecific imaging findings, to avoid unnecessary treatments. Nonetheless, urgent surgical intervention may be necessary in cases presenting with intestinal occlusion or uncontrolled pain.

Upper and Lower Endoscopic Findings in Mesenteric Panniculitis Patients: A Case-Control Study

Background: The natural history and prognosis of mesenteric panniculitis (MP) are not well-described. Despite referral for colonoscopy being common for this indication, colonoscopy findings in MP patients have not been reported. Therefore, we aimed to describe upper and lower gastrointestinal (GI) endoscopy findings in patients with mesenteric panniculitis, compared to matched controls, to investigate their clinical outcomes including incidence of malignancy and mortality. Methods: Retrospective case-control study was conducted, and included patients who were diagnosed with mesenteric panniculitis according to Coulier radiologic criteria on abdominal computerized tomography between 1/2005 and 12/2019, and followed to 12/2021. The case group was compared to a matched control group without MP on abdominal CT. Clinical data and the upper and lower endoscopies' reports were reviewed in both groups. We excluded patients who, beyond diagnosis of MP, were also diagnosed with current malignancy, significant intra-abdominal morbidity or inflammatory bowel disease. Results: The initial set of 376 patients with MP, after exclusion, included 187 patients. A total of 56.1% were male, with a mean age 60 ± 15 years. Of them, 74 (39%) patients underwent follow-up CT scans, which demonstrated, in 66 (89.2%) patients, a stable MP without any aggravation. Colonoscopy was performed in 89 MP patients, and 98/187 controls. No significant difference in the colonoscopies' findings was found between the two groups. Gastroscopy was performed in 84 MP and 79 controls. No case of gastric cancer was found. No statistically significant difference was found in the rate of gastroscopy findings. By the end of the follow-up period, malignancy was diagnosed in four patients of the MP group. None were colon cancer. The mortality rate in the MP group was 3.2%, without a significant difference compared to the controls. None were MP related. Conclusions: MP identified on abdominal CT is not associated with pathologic endoscopy findings or future diagnosis of colon cancer, and also has no impact on mortality rate. Since repeating abdominal CT did not reveal any disease progression, the necessity of follow-up imaging for MP should be carefully reconsidered.

Association between mesenteric panniculitis and urolithiasis

BACKGROUND

Mesenteric panniculitis is a rare condition and refers to benign and nonspecific inflammation of mesenteric fat.

OBJECTIVES

This study aimed to evaluate the hypothesis of a greater prevalence of mesenteric panniculitis in patients with urolithiasis.

MATERIALS AND METHODS

In this cross-sectional study, abdominopelvic CT scans of 500 patients were reviewed for the presence of urolithiasis and mesenteric panniculitis. The inclusion criteria were patients who were referred with acute abdominal pain and were suspected of having urolithiasis or other urinary conditions and who had undergone abdominopelvic CT scan. Subcutaneous fat thickness was measured, and pain intensity was recorded by patient evaluation.

RESULTS

Mesenteric panniculitis was found in 10 patients, all of whom (100%) had urinary stones (ureter or kidney or both), and none of them had previous surgeries or known malignancies. The prevalence of panniculitis was significantly greater in the group with urolithiasis. In the urolithiasis group, subcutaneous fat thickness was greater in patients with panniculitis, although the difference was not statistically significant. In the subgroup analysis, pain intensity was not significantly greater in patients with panniculitis.

CONCLUSION

Mesenteric panniculitis is more prevalent among patients with urolithiasis, but it seems that it does not change the intensity of the pain.

Relapsing sclerosing mesenteritis with multiple strictures of the small intestine

Sclerosing mesenteritis (SM) is a rare disorder that involves the mesenteric adipose tissue with chronic fibrosing inflammation. Few reports mention the natural history of severe SM cases. Here, we report a severe and relapsing SM case in which a long-term natural history could be followed. The patient had undergone surgery for small bowel stenosis of unknown cause 10 years earlier. He had stopped visiting the hospital at his discretion. He was admitted to the hospital 10 years later due to recurrent symptoms, and a close examination revealed multiple small intestinal strictures; thus, surgery was performed again. The pathological results revealed that the patient had SM, corticosteroid administration dramatically improved his symptoms, and he has maintained remission for a long time.

A clinician's perspective on the new organ mesentery and non-vascular mesenteropathies

Mesentery was discovered as a new organ in 2017. It is a continuous membranous tissue from the duodenojejunal flexure to the anorectal junction. It has distinct anatomy, physiology, and disease states. Primary mesenteropathies include vascular and non-vascular diseases. Some of them are common, and some of them are rarely seen in clinical practice. Secondary mesenteropathies occur when infection or malignancy in another organ spreads to the mesentery. Each entity has specific diagnostic and treatment protocols. Increased awareness of different mesenteropathies and an understanding of their various presentations at different stages of life can help in early diagnosis and improved clinical outcomes.

The Long-Term (3.5-Year) Observation of Asymptomatic Sclerosing Mesenteritis: A Case Report

A 57-year-old male with a history of hypertension, diabetes mellitus, and dyslipidemia was found to have elevated carcinoembryonic antigen (CEA) levels during a routine health checkup, leading to an abdominal computed tomography (CT) scan. The scan identified a mesenteric mass with an irregular morphology. Subsequent blood tests indicated no signs of inflammation, and follow-up CEA levels normalized. Further imaging with abdominal contrast-enhanced CT and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET)/CT revealed a calcified mass in the mesentery, raising concerns for malignancy. However, an exploratory laparotomy and biopsy confirmed the diagnosis of sclerosing mesenteritis (SM). During a 3.5-year period, the patient remained asymptomatic, with serial imaging showing no significant changes in the mass, even without treatment. This case underscores the potential benign course of SM, suggesting that conservative management may be appropriate in select asymptomatic cases.

Idiopathic hyalinizing fibrosclerosis: A systemic steroid-resistant condition distinct from IgG4-related disease

Since the concept of IgG4-related disease (IgG4-RD) was proposed, that diagnosis has been considered in idiopathic fibroinflammatory diseases in various organs, particularly in cases with multi-organ involvement. We have recently encountered three cases of fibrosing disease of uncertain etiology with shared microscopic appearances. Case 1 (56-year-old man) had an irregular mass at the base of mesentery. Case 2 (29-year-old woman) presented with obstructive jaundice due to an ill-defined mass at the hepatic hilum and two lung nodules. Case 3 (53-year-old man) had multiple solid nodules in the mediastinum, peritoneum, retroperitoneum, and mesentery; he also had diffuse irregular narrowing of the intra- and extra-hepatic bile ducts in keeping with sclerosing cholangitis. Serum IgG4 concentrations were not elevated. Biopsies from the nodular lesions showed extensive hyalinizing fibrosis with an only focal lymphoplasmacytic infiltrate. Thick collagenous bundles are arranged in an irregular or partly whorl pattern. Typical storiform fibrosis or obliterative phlebitis was not observed. The number of IgG4-positive plasma cells was <10 cells/high-power field; the ratio of IgG4/IgG-positive plasma cells was <30%. After the histological diagnosis of sclerosing mesenteritis, pulmonary hyalinizing granuloma, and mediastinal fibrosis was made, they were treated with a trial of steroids, but none showed a significant response. In conclusion, a hyalinizing fibrotic condition can occur at various anatomical sites. They have shared microscopic findings, and are steroid-resistant. Although the clinical presentation may mimic IgG4-RD, the two conditions are likely distinct. We would propose a diagnostic term of 'idiopathic hyalinizing fibrosclerosis' for this under-recognized, rare, systemic condition.

Sclerosing mesenteritis as a cause of porto-mesenteric vascular obstruction

A woman in her 20s presented with haematemesis, post-prandial abdominal pain, weight loss and anaemia. Imaging revealed a non-enhancing mass in the retroperitoneal space along the mesenteric plane, encasing the porto-mesenteric vasculature. Endoscopy showed oesophageal varices. She was diagnosed with sclerosing mesenteritis, causing extrinsic compression of the portal vein and superior mesenteric artery. She underwent endoscopic variceal ligation and received prednisolone and tamoxifen. After 3 months, her post-prandial pain improved, and she did not have further bleeding episodes.

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.

The over diagnosis of diffuse mesothelioma: An analysis of 311 cases with recommendations for the avoidance of pitfalls

BACKGROUND

The diagnosis of mesothelioma may be challenging. We investigated a large database of cases in order to determine the frequency with which a diagnosis of mesothelioma was made incorrectly and the most frequent causes of error.

DESIGN

A database including more than 4000 consultation cases of histologically confirmed mesothelioma was examined to identify cases in which mesothelioma was diagnosed by at least one pathologist when the available information pointed towards a different diagnosis.

RESULTS

There were 311 cases misdiagnosed as mesothelioma. The most common category was metastatic carcinoma to the pleura or peritoneum (129 cases: 73 lung carcinomas, 15 renal cell carcinomas). The next most common category was primary lung cancer (111 cases: 55 sarcomatoid carcinoma, 56 pseudomesotheliomatous carcinoma). The third most common category was primary malignancies arising from or near the serosal membranes (33 cases). The fourth most common category was fibrous pleurisy (38 cases). The most common errors were failure to consider important radiographic information regarding the gross distribution of tumor, lack of awareness or consideration of another malignancy, overreliance on certain immunohistochemical results, and failure to perform certain diagnostic histochemical, immunohistochemical, or ultrastructural studies.

CONCLUSIONS

There are a number of diagnostic pitfalls that can lead to the over diagnosis of mesothelioma. Careful attention to clinical and radiographic information as well as performance of appropriate ancillary tests can help to prevent such misdiagnoses. Detailed examples will be presented to assist in the avoidance of these pitfalls with emphasis on the most commonly observed errors.

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.

Benign Mesenteric Lesion Presenting with Features of a Malignant Mass

Encapsulated fat necrosis (EFN), most commonly, is an asymptomatic entity and is often found incidentally in images. However, in the abdomen, it may present as an acute abdomen. Mesenteric fat necrosis is part of a larger disease spectrum called collectively mesenteric sclerosis. It results in forming of a mass that can be confused with other pathologies such as liposarcoma, carcinoma of the cecum, and other more benign conditions such as appendagitis of the epiplon. We present the case of an 82-year-old male who presented with an asymptomatic right lower quadrant mass with concerning computed tomography findings with no previous abdominal surgery or trauma history. Diagnosing EFN is crucial as it can mimic bowel cancer and immune-related mesenteric pathology such as sclerosing mesenteritis, the management of which is far more extreme and aggressive than EFN.

Fatal sclerosing mesenteritis: a 7-year-old male autopsy case report

Sclerosing Mesenteritis (SM) is a rare diagnosis, particularly in pediatric patients, and is typically non-fatal when appropriately treated. Although molecular and immunohistochemical alterations have been described, no pathognomonic signature has been identified for this entity. This report presents a case of a seven-year-old boy who suffered sudden cardiorespiratory arrest. Upon autopsy, he was found to have multicentric SM on the upper mesentery, which led to bowel wall thinning and abdominal bleeding with bacterial translocation. We performed comprehensive morphological, immunohistochemical, and molecular analyses. SM is an atypical disorder with diverse clinical manifestations, including a rare but potentially fatal course. Early diagnosis is critical, given its potential severity. To our knowledge, this is the first case report of pediatric mortality linked to SM. Our findings emphasize the importance of increased awareness and early detection of SM in pediatric patients.

Idiopathic sclerosing mesenteritis presenting with small bowel volvulus in a patient with antiphospholipid syndrome: A case report

BACKGROUND

Sclerosing mesenteritis is a rare disorder involving inflammation of the mesentery. Its etiology remains unclear, but it is believed to be associated with previous abdominal surgery, trauma, autoimmune disorders, infection, or malignancy. Clinical manifestations of sclerosing mesenteritis are varied and include chronic abdominal pain, bloating, diarrhea, weight loss, formation of an intra-abdominal mass, bowel obstruction, and chylous ascites. Here, we present a case of idiopathic sclerosing mesenteritis with small bowel volvulus in a patient with antiphospholipid syndrome.

CASE SUMMARY

A 68-year-old female presented with recurrent small bowel obstruction. Imaging and pathological findings were consistent with sclerosing mesenteritis causing mesenteric and small bowel volvulus. Computed tomography scans also revealed pulmonary embolism, and the patient was started on a high dose of corticosteroid and a therapeutic dose of anticoagulants. The patient subsequently improved clinically and was discharged. The patient was also diagnosed with antiphospholipid syndrome after a hematological workup.

CONCLUSION

Sclerosing mesenteritis is a rare condition, and patients with no clear etiology should be considered for treatment with immunosuppressive therapy.

Conservative Management of Mesenteric Panniculitis in a Remote Island

INTRODUCTION

Mesenteric panniculitis (MP) includes a spectrum of nonspecific fibroinflammatory disorders of unknown aetiology that affects mainly the root of the mesentery. Case Report. A 68-year-old man is incidentally diagnosed with MP during follow-up investigation for a fusiform coeliac artery aneurysm. Four years since the diagnosis, he is completely asymptomatic. After discussing with him and presenting the current evidence, he decided not to proceed with biopsy because the finding was incidental and he is asymptomatic. Moreover, tumour markers were within the normal range. He has been scheduled for annual follow-ups with computerized tomography (CT) scans and tumour markers.

CONCLUSIONS

MP is a rare chronic fibroinflammatory disease with contradictory evidence regarding its definition and management. Watchful follow-ups with CT scan and tumour markers are recommended for asymptomatic patients.

Circulating fibrocyte percentage and neutrophil-lymphocyte ratio are accurate biomarkers of uncomplicated and complicated appendicitis: a prospective cohort study

BACKGROUND

There is increasing evidence that uncomplicated appendicitis (UA) may be treated nonoperatively in cases of UA. This study aimed to evaluate and compare the diagnostic accuracy of circulating fibrocyte percentage (CFP), white blood cell count, C-reactive protein, and neutrophil-lymphocyte ratio (NLR) in diagnosing uncomplicated and complicated appendicitis.

MATERIALS AND METHODS

Eighty consecutive adult patients presenting with suspected appendicitis were recruited in a cohort-based prospective study between June 2015 and February 2016 at University Hospital Limerick in Ireland. Peripheral venous samples were obtained at the presentation. Clinical, biochemical, radiological, and histopathological parameters were recorded. The CFP was determined by dual-staining for CD45 and collagen-I using flow cytometry analysis and correlated with histopathological diagnoses.

RESULTS

Of the 46 patients who underwent appendicectomy, 34 (73.9%) had histologically proven acute appendicitis. A comparison of the diagnostic accuracy of biomarkers demonstrated the CFP had the highest diagnostic accuracy for UA (area under the curve=0.83, sensitivity=72.7%, specificity=83.3%, P=0.002). The NLR had the highest diagnostic accuracy in relation to complicated appendicitis (area under the curve=0.84, sensitivity=75.5%, specificity=83.3%, P=0.005).

CONCLUSIONS

CFP and NLR are accurate biomarkers of UA and complicated appendicitis.

Mesenteric panniculitis: a clinical conundrum

Mesenteric panniculitis is encountered frequently during abdominopelvic CT scanning, often as an incidental finding. The observation is problematic because an association with malignancy has been raised in the literature. This review will describe the CT appearances and examine the available evidence regarding the significance of this finding.Ultimately, the literature remains unclear regarding how these patients should be managed, if at all.

Sclerosing Mesenteritis Managed Conservatively With Prednisone

The authors present the case of a middle-aged lady with two weeks of abdominal pain. Computed tomography imaging revealed sclerosing mesenteritis. Sclerosing mesenteritis is also known as mesenteric panniculitis and is a chronic fibrosing inflammatory disease that primarily affects the adipose tissue of the mesentery in the small intestine and colon. The clinical presentation, imaging findings, differential diagnosis, and therapeutic management are presented in this report. In our patient's case, she was able to be managed conservatively, without the need for surgery. This reflects the most benign and self-limiting natural history of the disease.

Successful treatment of sclerosing mesenteritis with tamoxifen monotherapy

Sclerosing mesenteritis is a rare disorder characterized by fat necrosis, chronic inflammation, and fibrosis of the small bowel mesentery. With a paucity of published clinical trials on sclerosing mesenteritis, treatment is based on case reports and trials of other fibrosing diseases, such as idiopathic retroperitoneal fibrosis. We present a case of a 68-year-old woman with sclerosing mesenteritis who exhibited complete symptomatic and radiographic resolution with the use of tamoxifen monotherapy.

Visceral extra-abdominal panniculitis after COVID19

"Retractile mesenteritis" was the first name given to a rare, benign, inflammatory disease that affects the adipose tissue of the intestinal mesentery and less frequently other locations. Now labeled as mesenteric panniculitis, the pathogenic mechanism remains unclear. Several stimuli could be involved, and it is sometimes associated with other conditions such as malignancy or autoimmune diseases. We present a case of mesenteric panniculitis with extensive abdominal and extra-abdominal involvement that developed a few months after SARS-COV2 infection, raising the hypothesis of this virus as a potential trigger for autoinflammatory and autoimmune diseases.

Mesenteric panniculitis is associated with cardiovascular risk-factors: A case-control study

BACKGROUND

This study evaluated the prevalence of cardiovascular risk-factors in patients with mesenteric panniculitis.

AIMS

To determine whether cardiovascular risk-factors and mesenteric panniculitis are associated.

METHODS

Retrospective, matched case-control study of patients referred to Meir Medical Center, Israel, 2014-2019, who underwent computerized tomography scan, were diagnosed mesenteric panniculitis by radiologic criteria. They were compared to two, matched case-control groups: hospitalized patients without mesenteric panniculitis and the general population based on Israeli Ministry of Health surveys. Patients with active malignancy, IBD or significant intra-abdominal morbidity were excluded.

RESULTS

Of 376 patients with mesenteric panniculitis diagnosed by computerized tomography, 187 were included. Compared to hospital patients, they had higher incidence of dyslipidemia (77.5%/56.7%), hypertension (52.4%/40.6%), obesity (body mass index>30) (60.4%/30.5%) and nonalcoholic fatty liver disease (42.2%/16.6%). Similar differences were observed compared to the general population. In multivariable logistic regression, dyslipidemia, obesity, and nonalcoholic fatty liver disease were independent predictors for mesenteric panniculitis.

CONCLUSIONS

Patients with mesenteric panniculitis have more cardiovascular risk-factors compared to a case-control group and to the general population. This suggests that mesenteric panniculitis is clinically significant and may be part of the metabolic morbidity burden. This association should be further explored.

An Unusual Cause of Acute Abdominal Pain in Coronavirus Disease (COVID-19): Report of Two Cases

Coronavirus disease-2019 (COVID-19) is an infectious disease caused by coronavirus/2019-nCoV. It primarily manifests as lung infection, with fever and respiratory tract symptoms. Extrapulmonary complications affecting multiple organs are commonly seen, especially in critically ill patients. The reported gastrointestinal (GI) complications include transaminitis, acute pancreatitis, mesenteric ischemia, GI bleed, and ileus. Here, we report two cases of acute abdominal pain in patients with COVID-19 in their second week of illness. One patient had mild COVID-19 disease and the other had severe disease. Both patients had diffuse abdominal tenderness and raised inflammatory markers. The diagnosis of mesenteric panniculitis (MP) was made radiologically, and demonstrated with the presence of increased density of the mesentery with fat stranding (misty mesentery). Glucocorticoid administration resulted in the complete resolution of pain. They remained pain-free at 3 months of follow-up.

Mesenteric panniculitis various presentations and management: A single institute ten years, experience

Mesenteric Panniculitis (MP) is predominately a disease of the small bowel of unknown etiology. Characterized by Fibrosis and chronic inflammation of fatty tissue of the mesentery in the small bowel. It is commonly diagnosed based on computed tomography (CT scan) with IV contrast and biopsies in equivocal cases. We conducted a retrospective study from 2011 to 2020. We analyzed the medical records of 40 patients with Mesenteric Panniculitis. The most common presentation was vague abdominal symptoms. We successfully managed the patients medically with prednisone, azathioprine, colchicine, or a combination. Patients on prednisolone showed good responses clinically and radiologically during follow-up. One patient was operated on and didn't respond to medical therapy.

CT features associated with underlying malignancy in patients with diagnosed mesenteric panniculitis: Mesenteric panniculitis: CT features associated with underlying malignancy

PURPOSE

The purpose of this study was to identify abdominal computed tomography (CT) features associated with underlying malignancy in patients with mesenteric panniculitis (MP).

MATERIALS AND METHODS

This single-institution retrospective longitudinal cohort study included patients with MP and a minimum 1-year abdominopelvic CT follow-up or 2-year clinical follow-up after initial abdominopelvic CT examination. Two radiologists, blinded to patients' medical records, conjointly reviewed CT-based features of MP. Electronic medical records were reviewed for newly diagnosed malignancies with the following specific details: type (lymphoproliferative disease or solid malignancy), location (possible mesenteric drainage or distant), stage, time to diagnosis. An expert panel of three radiologists and one hemato-oncologist, who were blinded to the initial CT-based MP features, assessed the probability of association between MP and malignancy based on the malignancy characteristics.

RESULTS

From 2006 to 2016, 444 patients with MP were included. There were 272 men and 172 women, with a median age of 64 years (age range: 25-89); the median overall follow-up was 36 months (IQR: 22, 60; range: 12-170). A total of 34 (8%) patients had a diagnosis of a new malignancy; 5 (1%) were considered possibly related to the MP, all being low-grade B-cell non-Hodgkin lymphomas. CT features associated with the presence of an underlying malignancy were the presence of an MP soft-tissue nodule with a short axis >10 mm (P < 0.0001) or lymphadenopathy in another abdominopelvic region (P < 0.0001). Associating these two features resulted in high diagnostic performance (sensitivity 100%; [95% CI: 57-100]; specificity 99% [95% CI: 98-100]). All related malignancies were identified.

CONCLUSION

Further workup to rule out an underlying malignancy is only necessary in the presence of an MP soft-tissue nodule >10 mm or associated abdominopelvic lymphadenopathy.

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.

Mesenteric Panniculitis Appears as Metastatic Disease on 18F-FDG-PET/CT Scan

Mesenteric panniculitis is a rare benign inflammatory process involving mesenteric adipose tissue and the pathogenesis is still unknown. It may present ¹⁸Fluorine-fluorodeoxyglucose (¹⁸F-FDG) uptake and appear like a malign tumor or metastatic disease. We report a case of 47 year-old woman with serous ovarian adenocarcinoma demonstrating intense ¹⁸F-FDG uptake and hyperdense nodularity in mesenteric fatty tissue on post-chemotherapy positron emission tomography/computed tomography imaging. The serum tumor marker (CA-125) level was within the normal range. A correlative magnetic resonance imaging highlighted the diagnosis of mesenteric panniculitis that was also confirmed by clinical follow-up.

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.

Mesenteric panniculitis does not confer an increased risk for cancers: A systematic review and meta-analysis

BACKGROUND

Mesenteric panniculitis (MP) is a non-specific, localized inflammation at the mesentery of small intestines which often gets detected on computed tomography. An association with malignant neoplasms remains unclear. We performed a systematic review and meta-analysis to examine the association of malignancy with MP.

METHODS

MEDLINE, EMBASE, Web of Science, and Cochrane databases were searched for articles published from inception to 2020 that evaluated the association of malignant neoplasms with MP in comparison with control groups. Using random-effects method, a summary odds ratio (OR) estimate with 95% confidence intervals for malignant neoplasms in MP was estimated.

RESULTS

Four case-control studies reporting data on 415 MP patients against 1132 matched-controls met inclusion criteria and were analyzed. The pooled OR for finding a malignant neoplasm in patients with MP was 0.907 (95% CI: 0.688-1.196; P = .489). The heterogeneity was mild and non-significant. Also, there was no heightened risk of any specific type of malignancy with MP. Three more case-series with unmatched-control groups (MP: 282, unmatched-controls: 17,691) were included in a separate analysis where the pooled OR of finding a malignant neoplasm was 2.963 (95% CI: 1.434-6.121; P = .003). There was substantial heterogeneity in this group.

CONCLUSION

This meta-analysis of matched controlled studies proves absence of any significant association of malignant neoplasms with MP. Our study also demonstrates that the putative association of malignancy with MP is mainly driven by uncontrolled studies or case-series.

Mesenteric Panniculitis and COVID-19: A Rare Association

Coronavirus disease 2019 (COVID-19) typically involves the respiratory system, but gastrointestinal involvement is common. Further, patients with severe COVID-19 are at high risk to develop gastrointestinal complications, including bowel ischemia, ileus, and deranged liver enzymes. We present the case of a 44-year-old woman with mild COVID-19 pneumonia who was in home isolation. Ten days after the isolation, the patient presented to the emergency department complaining of generalized abdominal pain that was sharp in nature and associated with nausea and recurrent episodes of vomiting. The patient did not complain of any respiratory symptoms. Physical examination showed diffuse tenderness with no clinical signs to suggest generalized peritonitis. The laboratory parameters showed normal hematological, renal, and hepatic profiles. No elevation in the inflammatory markers was observed. The amylase level was within the normal range. Abdominal computed tomography scan demonstrated the presence of misty mesentery with increased density of the mesentery with fat stranding encasing the mesenteric vessels along with mesenteric adenopathy. Such radiological features suggested the diagnosis of mesenteric panniculitis. Subsequently, intravenous corticosteroid therapy was initiated and the patient exhibited significant improvement after 24 hours. The patient was discharged after nine days of hospitalization. She was followed up after one month and she had no complaints. Mesenteric panniculitis is a rare idiopathic inflammatory condition involving the mesenteric adipose tissue. The case shed a light on the possible association of COVID-19 with mesenteric panniculitis. The clinical manifestations of mesenteric panniculitis are non-specific and imaging studies are essential to suggest the diagnosis.

Nodular Sclerosing Mesenteritis: An Occasional Finding Mimicking a Spindle Cell Tumor

BACKGROUND The term "sclerosing mesenteritis" includes a spectrum of rare idiopathic diseases involving the small and/or large bowel. It appears as a diffuse, localized, or multinodular thickening of the mesentery, with a variable degree of chronic non-specific inflammation, fat necrosis, and fibrosis. CASE REPORT Here, we report a case of 83-year-old woman with symptoms of intestinal occlusion, vomiting, and abdominal pain. Radiographic examinations showed air fluid levels in right and left quadrants and in the mesogastric site, while computed tomography (CT) documented a strangulated inguinal hernia with ileal obstruction. Based on clinical examination and radiologic findings, the patient underwent surgery for inguinal hernia reduction. The examination of viscera revealed 2 tracts of ileum with ischemic signs and covered by fibrin; thus, the 2 intestinal loops were resected. Histological examination revealed chronic non-specific inflammation of the whole intestinal wall, including the subserosa in the resected tract of proximal ileum, while the distal ileal loop (not herniated tract) showed a subserosal fibrous nodule of 2 cm in greatest diameter, composed of a proliferation of spindle cells haphazardly arranged in a collagenized stroma. The diagnosis of sclerosing mesenteritis was rendered. CONCLUSIONS The present case shows the possibility of an incidental diagnosis during another intervention such as hernia surgery. Pathologists should be aware of this disease to avoid confusion with aggressive tumors such as intra-abdominal desmoid-type fibromatosis and gastrointestinal stromal tumor.

Sclerosing Mesenteritis, a Rare Cause of Mesenteric Mass in a Young Adult: A Case Report

Sclerosing mesenteritis (SM) is a rare fibroinflammatory disorder that involves mesenteric adipose tissue, more frequently localized in the small intestine, with an insidious clinical presentation having symptoms related to mass effect, usually resulting in bowel obstruction, mesenteric ischemia, as well as rapid weight loss. We report a case of a 23-year-old male presenting with palpable abdominal mass, mesogastric pain, and a history of rapid weight loss, who underwent exploratory laparoscopy. A hemorrhagic and gelatinous nodular tumor mass of the mesentery was identified and the surgical procedure was converted to a laparotomic approach. Histologically, the mass was composed of a proliferation of bland-looking spindle cells with slightly eosinophilic cytoplasm and elongated normochromatic nuclei with mild nuclear atypia, haphazardly set in a collagenized stroma; fat necrosis and inflammatory cells (lymphocytes, plasma-cells, and histiocytes) were also evident. The diagnosis of sclerosing mesenteritis was made. Our case emphasizes that histology remains pre-eminent for a correct diagnosis of SM, as pre-operative radiological-based diagnosis is non-specific.

[Motility disorder and weight loss in a 71-year-old male patient]

A 71-year-old man presented to this clinic for evaluation of an unclear abdominal tumor. He complained of abdominal pain, weight loss and motility disorders, which began some weeks previously. Ultrasound and computed tomography (CT) scans showed a large mesenterial space-occupying lesion with accompanying lymphadenopathy, slight accumulation of ascites and venous congestion. For confirmation of the suspected diagnosis of a sclerosing mesenteritis and exclusion of a lymphoma a laparoscopy was carried out with excision of tissue. The material was not adequately representative so that a laparotomy was carried out for removal of a new tissue specimen. The tissue specimen confirmed the rare diagnosis of sclerosing mesenteritis and due to the complaints a pharmaceutical treatment with prednisone and tamoxifen was initiated.

Peritoneal or mesenteric tumours revealing histiocytosis

Objective

Peritoneal or mesenteric tumours may correspond to several tumour types or tumour-like conditions, some of them being represented by histiocytosis. This rare condition often poses diagnostic difficulties that can lead to important time delay in targeted therapies. Our aim was to describe main features of histiocytoses with mesenteric localisation that can improve the diagnostic process.

Design

We performed a retrospective study on 22 patients, whose peritoneal/mesenteric biopsies were infiltrated by histiocytes.

Results

Abdominal pain was the revealing symptom in 10 cases, and 19 patients underwent surgical biopsies. The diagnosis of histiocytosis was proposed by initial pathologists in 41% of patients. The other initial diagnoses were inflammation (n=7), sclerosing mesenteritis (n=4) and liposarcoma (n=1). The CD163/CD68+CD1a- histiocytes infiltrated subserosa and/or deeper adipose tissues in 16 and 14 cases, respectively. A BRAF^V600E mutation was detected within the biopsies in 11 cases, and two others were MAP2K1 mutated. The final diagnosis was histiocytosis in 18 patients, 15 of whom had Erdheim-Chester disease. The median diagnostic delay of histiocytosis was 9 months. Patients treated with BRAF or MEK inhibitors showed a partial response or a stable disease. One patient died soon after surgery, and five died by the progression of the disease.

Conclusion

Diagnosis of masses arising in the mesentery should be carefully explored as one of the possibilities in histiocytosis. This diagnosis is frequently missed on mesenteric biopsies. Molecular biology for detecting the mutations in BRAF or in genes of the MAP kinase pathway is a critical diagnostic tool.

Systemic manifestations - do not forget the small bowel

PURPOSE OF REVIEW

Systemic diseases can afflict the small bowel (SB) but be challenging to diagnose. In this review, we aim to provide a broad overview of these conditions and to summarise their management.

RECENT FINDINGS

Small bowel capsule endoscopy (SBCE) is an important modality to investigate pathology in the SB. SB imaging can be complementary to SBCE for mural and extramural involvement and detection of multiorgan involvement or lymphadenopathy. Device assisted enteroscopy provides a therapeutic arm, to SBCE enabling histology and therapeutics to be carried out.

SUMMARY

SB endoscopy is essential in the diagnosis, management and monitoring of these multi-system conditions. Collaboration across SB centres to combine experience will help to improve the management of some of these rarer SB conditions.

Ultrasonography-Based Management of Sclerosing Mesenteritis: From Diagnosis to Follow-Up

Sclerosing mesenteritis (SM) is an idiopathic disorder affecting mesentery, characterized by fat necrosis, chronic inflammation and fibrosis. The clinical presentation varies from asymptomatic cases to acute abdomen. The diagnosis is suggested by imaging but can be definitely established only by biopsies. In this paper, we discuss ultrasonography-based management of SM.

[Imaging of Mesentery and Omentum]

Although primary tumors in the mesentery and omentum are relatively rare, it is often necessary to distinguish them from other non-tumorous diseases. Since the omentum and mesentery are major routes for the spread of various abdominal diseases, the anatomy, type, and pattern of the diseases affecting these organs should be known in detail for accurate differential diagnosis. In addition, it is important to detect and promptly treat hidden lesions in the mesentery and omentum. Therefore, careful observation of the area where the lesion occur should be emphasized when assessing mesentery and omentum in abdominal CT.

Surgical Excision of Sclerosing Mesenteritis, Exploration of an Unknown Mesenteric Mass

Sclerosing mesenteritis is a rare and often benign condition characterized as a fibrotic disease consisting of non-suppurative inflammation of adipose tissue. Through mass effect, sclerosing mesenteritis can compromise the gastrointestinal lumen as well as mesenteric vessel integrity. There is a poor understanding of this disorder and its pathogenesis, which presents with various symptomatology and often without identification of inciting factors. Patients with sclerosing mesenteritis exhibit gastrointestinal and systemic manifestations including weight loss, fever, nausea, vomiting, diarrhea, and abdominal pain. This case presents a patient with a seven-month history of chronic, epigastric abdominal pain following laparoscopic surgery for acute uncomplicated appendicitis. The patient underwent work-up with computed tomography and magnetic resonance enterography that confirmed the presence of a mesenteric mass of unknown etiology located in the mid-epigastrium. Due to the inability to safely sample the mass, the patient underwent diagnostic laparoscopy, which was subsequently converted to an open procedure where excision of the mesenteric lesion was performed. Surgical pathology revealed fat necrosis with fibrosis, granulomatous inflammation, and dystrophic calcifications consistent with sclerosing mesenteritis. The patient was seen in follow-up with the resolution of her epigastric abdominal pain. This case report demonstrates a unique presentation of a symptomatic patient with a mesenteric mass not amenable to non-invasive biopsy. Complete excision of this lesser sac mass revealed sclerosis mesenteritis as the pathological cause.

Unravelling the Mysteries of the Mesentery

The mesentery and its folds tether the small bowel loops to the posterior abdominal wall. It transmits nerves, vessels, and lymph ensconced in a fatty sponge layer wrapped in a thin glistening peritoneum, from and to the small bowel. Not only does this flexible dynamic fatty apron house various localized primary benign and malignant lesions, it is often involved in and gives an indication of generalized or systemic diseases in the body. An understanding of the anatomy, components, and function of the mesentery helps to classify mesenteric abnormalities. This further allows for characterizing radiological patterns and appearances specific to certain disease entities. Recent reviews of mesenteric anatomy have kindled new interest in its function and clinical applications, heralding the possibility of revision of its role in diseases of the abdomen.

Mesenteric Panniculitis in a Patient with Homozygous Factor V Leiden Gene Mutation: A Case and Literature to Review

A 30-year-old Asian male with a significant history of deep vein thrombosis and family history positive for pulmonary embolism presented with complaints of fever, nonradiating epigastric pain, and a sense of abdominal fullness. After the initial workup, ultrasonography of the whole abdomen was carried out which showed thrombus formation in the portal vein. A CT scan of the abdomen was performed, which showed findings suggestive of mesenteric panniculitis. Keeping the significant family history and imaging findings in mind, the clotting and thrombin profiles were analysed and came back positive for the factor V Leiden gene (homozygous). A CT angiogram was performed to demonstrate extensive thrombosis throughout the abdominal vasculature with cavernous transformation. It is asserted that the chronic thrombosis on a background of factor V mutation led towards chronic inflammation of the mesentery. To the authors’ knowledge it is the first reported case of mesenteric panniculitis in a patient with factor V homozygous gene mutation.

Sclerosing Mesenteritis Mimicking IgG4-related Disease

A 72-year-old man was followed as an outpatient at our hospital for 6 years after surgery for small cell carcinoma of left adrenal gland origin. Follow-up abdominal computed tomography showed a 6-cm mass in the left lower mesentery. The patient underwent open laparotomy. The histological diagnosis was sclerosing mesenteritis. The previous specimens of the left adrenal mass were then re-examined with a microscope, and panniculitis was found around the small cell carcinoma. Both lesions were histologically similar to IgG4-related disease (RD), but they did not completely meet the diagnostic criteria of IgG4-RD clinically or histologically.

Mesenteric panniculitis in a patient with new onset dermatomyositis

Mesenteric panniculitis (MP), part of the spectrum of sclerosing mesenteritis, is an often asymptomatic disorder that is characterised by chronic inflammation of abdominal mesentery. We present a case of an 83-year-old woman who presented with proximal muscle weakness and erythematous, photosensitive rash of the face and upper torso and was subsequently diagnosed with dermatomyositis based on skin biopsy, electromyography and muscle biopsy. She had radiographic evidence of panniculitis on CT scan of the abdomen and pelvis for malignancy surveillance, which improved on serial CT scan 3 months after beginning treatment for her underlying dermatomyositis with prednisone and mycophenolate mofetil. Our case highlights that MP can be associated with underlying autoimmune disease. Connective tissue disease could be considered in the differential of MP when other etiologies such as surgery, trauma and malignancy are ruled out.