Sclerosing mesenteritis: a comprehensive clinical review

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.

Diagnostic Dilemma: IgG4-Related Sclerosing Mesenteritis Mimicking an Abdominal Malignancy Enveloping the Superior Mesenteric Artery

Sclerosing mesenteritis, a rare fibroinflammatory disease affecting the mesentery, presents a diagnostic challenge due to its varied clinical manifestations and unknown etiology. We present a case of a 50-year-old female presenting with epigastric pain and weight loss, initially suspected of abdominal malignancy. Imaging revealed a mesenteric mass, and histopathological examination confirmed dense lymphoplasmacytic infiltrate with storiform fibrosis, along with elevated serum IgG4 levels, indicative of IgG4-related sclerosing mesenteritis. Treatment with thalidomide and prednisolone resulted in significant mass regression and symptom improvement. Our case highlights the importance of considering sclerosing mesenteritis in the differential diagnosis of abdominal masses and suggests a potential therapeutic approach for this rare condition. Further research is warranted to elucidate its pathogenesis and optimize management strategies.

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.

A Clinical Review of Mesenteric Panniculitis

Mesenteric panniculitis (MP) is a benign condition characterized by chronic inflammation and fibrosis of adipose tissue mainly of the small bowel mesentery. MP is commonly detected incidentally on cross-sectional imaging of the abdomen and can be asymptomatic in up to nearly half of patients. The most frequent clinical symptom reported is abdominal pain, followed by bloating/distention, diarrhea, constipation, vomiting, anorexia, weight loss, fever, malaise, and nausea. On computed tomography, MP is seen as a mass-like area of increased fat attenuation within the small bowel mesentery, usually located in the left upper quadrant of the abdomen. This mass-like area envelops mesenteric vessels and displaces adjacent bowel segments. Lymph nodes are frequently seen within the area of mesenteric abnormality. One of the most common differential diagnoses of MP is lymphoma, and positron emission tomography/computed tomography may be performed if there is suspicion of a concurrent underlying malignancy. Because of the benign nature of MP, treatment decisions should be guided by severity of symptoms and presence of complications. First-line medical treatment is prednisone and tamoxifen. Surgery is reserved for cases of recurrent bowel obstruction. This article provides a review of MP, including its epidemiology, pathophysiology, clinical presentation, imaging findings, and treatment.

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.

Sclerosing mesenteritis due to Mycobacterium genavense infection: A case report

RATIONALE

Since its first identification in the early 1990s, Mycobacterium genavense has been considered and opportunistic pathogen. It mainly causes gastrointestinal symptoms, but also disseminated infections in severely immunosuppressed patients. Sclerosing mesenteritis is a long-term complication with high morbidity and mortality. As it is a rare condition, there are no specific guidelines for its management. We report a challenging case of persistent M. genavense infection, and propose surgery as an alternative treatment strategy.

PATIENT CONCERNS

A 38-year-old Caucasian man presented to the emergency room with fever, abdominal pain, and night sweats for 3 months. HIV screening revealed a previously unknown HIV-1 infection, with a CD4 cell count of 216 cell/µL and viral load of 361.000 copies/mL at diagnosis. A body CT-scan showed mild splenomegaly as well as mesenteric and retroperitoneal enlarged lymph nodes. Fine needle aspiration revealed the presence of acid-fast bacilli, but mycobacterial cultures were negative. In the second sample, 16S RNA sequencing yielded a diagnosis of M. genavense infection. Despite 2 years of corticosteroids and antimycobacterial treatment excluding rifampicin due to a severe cutaneous reaction, there was no clinical improvement and an increase in the mesenteric lymph node size was observed, with a sclerosing transformation of the mesentery. A surgical approach was proposed to release small bowel loops and to remove fibrin. A second surgery was required due to an acute peritonitis ought to yeyunal segmental isquemia and perforation. Finally, the patient evolved favorably, and antimycobacterial drugs were suspended without relapse.

LESSONS

Despite a prolonged multidrug strategy, some patients develop persistent M. genavense infection. Once sclerosing mesenteritis is established, clinicians have few treatment options. Surgery should be considered in patients with sclerosing mesenteritis or bowel obstruction. The combination of medical and surgical treatment could be a potential cure for these patients.

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.

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.

Diagnostic Performance of Point Shear Wave Elastography (pSWE) Using Acoustic Radiation Force Impulse (ARFI) Technology in Mesenteric Masses: A Feasibility Study

Purpose: To evaluate the diagnostic performance of ultrasound point shear wave elastography (pSWE) using acoustic radiation force impulse (ARFI) technology in different benign and malignant mesenteric masses (MMs). Methods: A total of 69 patients with MMs diagnosed from September 2018 to November 2021 were included retrospectively in the study. The inclusion criteria were (1) an MM over 1 cm; (2) valid ARFI measurements; and (3) confirmation of the diagnosis of an MM by histological examination and/or clinical and radiological follow-up. To examine the mean ARFI velocities (MAVs) for potential cut-off values between benign and malignant MMs, a receiver operating characteristics analysis was implemented. Results: In total, 37/69 of the MMs were benign (53.6%) and 32/69 malignant (46.4%). Benign MMs demonstrated significantly lower MAVs than mMMs (1.59 ± 0.93 vs. 2.76 ± 1.01 m/s; p < 0.001). Selecting 2.05 m/s as a cut-off value yielded a sensitivity and specificity of 75.0% and 70.3%, respectively, in diagnosing malignant MMs (area under the curve = 0.802, 95% confidence interval 0.699–0.904). Conclusion: ARFI elastography may represent an additional non-invasive tool for differentiating benign from malignant MMs. However, to validate the results of this study, further prospective randomized studies are required.

Peritoneal Cancer Mimicking Sclerosing Mesenteritis: A Case Report

Peritoneal cancer is a rare disease that typically affects middle-aged women. Sclerosing mesenteritis can have a benign or malignant etiology. Although computed tomography (CT) scan and magnetic resonance imaging have been used to differentiate these two diseases, the findings are not always conclusive. Here, we report the case of an older woman who presented with acute abdominal pain. She was initially diagnosed with sclerosing mesenteritis, but the final diagnosis was peritoneal cancer. The initial treatment included antibiotics, non-steroidal anti-inflammatory drugs, and prednisolone. Tamoxifen was administered due to persistent symptoms, which were alleviated. However, the patient’s cancer antigen 125 levels were elevated, and there were changes in the peritoneal CT findings. The patient was diagnosed with primary peritoneal cancer based on further investigation of the peritoneum using positron emission tomography-CT and a biopsy. This case report describes the diagnostic process regarding the differentiation between sclerosing mesenteritis and primary peritoneal cancer when the CT findings mimic those of sclerosing mesenteritis in general medicine.

Idiopathic Sclerosing Mesenteritis: An Extremely Rare Cause of Mesenteric Mass

Idiopathic sclerosing mesenteritis (ISM) is an extremely rare condition in which mesenteric adipose tissue undergoes necrotic and fibrotic changes. It is also known as "retractile mesenteritis", "mesenteric panniculitis" or "fat necrosis of the mesentery". Most cases are seen in Caucasian males between the fifth and seventh decades of life. Some of the suggested causes of this extremely rare condition include autoimmune disorders, abdominal trauma, malignancy, abdominal infections and even IgG4-related diseases; however, the actual cause remains unknown. Most cases are either self-limiting or improve with medical therapy. However, aggressive cases requiring emergent surgical interventions to relieve intestinal obstruction have been reported in the literature. We present a case of a 60-year-old male patient who presented to the emergency room with severe abdominal pain and was diagnosed with ISM that required surgical intervention to relieve the symptoms.

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

Patient: Female, 83-year-old

Final Diagnosis: Sclerosing mesenteritis

Symptoms: Abdominal pain • intestinal obstruction • vomiting

Medication: —

Clinical Procedure: —

Specialty: Surgery

Colon Perforation As Initial Presentation of Refractory and Complicated Sclerosing Mesenteritis

Sclerosing mesenteritis (SM), a benign chronic fibrosing inflammatory disease of the mesentery, is a rare disease discovered in 1924. The prevalence of the disease is less than 1%. The exact etiology of the disease is not clear. It is thought that the integrity of the gastrointestinal lumen may be altered from chronic inflammatory effects. SM may be associated with autoimmune diseases, trauma, malignancy, or surgery. The most common clinical presentation is abdominal pain. Obstructive symptoms may occur. Diagnosis is made by CT abdomen and biopsy. Treatment includes surgical and immunosuppressive medications.

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.

Ileal Neuroendocrine Tumor in a Patient with Sclerosing Mesenteritis: Which Came First?

BACKGROUND Jejunoileal neuroendocrine tumors (JI-NETs) are rare tumors that can be associated with mesenteric fibrosis. This case report is of an incidental finding of a JI-NET in a patient who was previously misdiagnosed with sclerosing mesenteritis. CASE REPORT A 42-year-old man was admitted to our institution with diffuse abdominal pain and clinical and radiographic signs of bowel obstruction. He had a previous diagnosis of sclerosing mesenteritis, which had been histologically diagnosed after an exploratory laparoscopy performed in 2009 for recurrent acute abdominal pain. He was also annually monitored through computed tomography scans for an incidentally discovered, gradually enlarging mesenteric mass for which a "wait and watch" management approach was adopted. After a period of fasting and observation, the patient underwent an urgent exploratory laparotomy because of his worsening condition. Intraoperatively, an ileocecal resection was performed, along with excision of the known mesenteric mass. The pathology report revealed an ileal NET with nodal metastases within the mesentery and mesenteric tumor deposits (pT3N1). CONCLUSIONS JI-NETs are rare entities, which are usually encountered as incidental findings or in patients with unspecific abdominal pain. Our case represents a probable delayed diagnosis of JI-NET in the context of sclerosing mesenteritis; therefore, a possible association between these 2 conditions should be investigated.

The Use of Glucocorticoids for Better Control of Diabetes Mellitus: The Paradox of Sclerosing Mesenteritis (The Rare Could Become Common)

Patient: Male, 57-year-old

Final Diagnosis: Sclerosing mesenteritis

Symptoms: Abdominal pain

Medication: Prednisone

Clinical Procedure: CT scan • MRI

Specialty: Endocrinology and Metabolic

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.

Bilateral pleural effusions as the first sign of mesenteric panniculitis

A 38-year-old woman presented to the emergency department with a history of thoracic pain and anorexia for 1 week. Thoracic CT scan showed bilateral pleural effusion, a thoracentesis was performed revealing a transudate liquid with polymorphonuclears and predominance of eosinophils. After admission, the patient developed abdominal pain and the abdominal CT scan showed densification of the mesenteric fat characteristic of mesenteric panniculitis (MP). The patient went through investigation for secondary causes of panniculitis including infection, neoplasia and autoimmune diseases, and no abnormalities were found. The patient was treated with corticosteroids over a period of 3 months with complete resolution and without any signs of remission or secondary cause of MP. Moreover, the patient remained asymptomatic for 2 years after being discharged, which strengthens the diagnosis of MP that presented with eosinophilic pleural effusion.

A severe case of sclerosing mesenteritis

Sclerosing mesenteritis is a rare benign disease presenting with chronic inflammation of the mesenteric adipose tissue and variable degrees of fibrosis. A 47-year-old black man presented to the emergency department with symptoms of small bowel obstruction, requiring surgical treatment. The laparotomy revealed a stenosis of the distal ileum with mesenteric thickening and an enterectomy was performed. The postoperative period was complicated by the maintenance of bowel obstruction. The patient underwent a second laparotomy, in which the fibrosing process of the mesentery was much aggravated, and an ileo-colic resection was needed. After knowledge of the histological diagnosis, the patient was started on immunomodulators with clinical improvement. At 26 months of follow-up, patient is asymptomatic under medical treatment. This is the first report, to our knowledge, of a patient with progressive fibrosis in such short period of time requiring surgical re-intervention for bowel obstruction, owing to sclerosing mesenteritis.