A Rare Case of Symptomatic Mesenteric Panniculitis

Abstract

Mesenteric panniculitis is an uncommon inflammatory disorder of the intestinal mesentery belonging to a spectrum of idiopathic disorders termed sclerosing mesenteritis. Clinical presentation ranges widely from asymptomatic to bowel obstruction. We present a rare case of symptomatic mesenteric panniculitis. A 59 y/o female with a history of ischemic colitis presented to the ED with progressive epigastric and left lower quadrant abdominal pain, nausea, and constipation. Physical exam revealed a distended, diffusely tender abdomen with bloodwork showing a WBC of 18,000 cells/microL. CT scan showed focal dilation of small bowel without discrete obstruction. EGD and gastric emptying study were unremarkable. Given her persistent abdominal pain a follow up MR enterography was performed which showed mesenteric stranding (Figure 1) and prominent lymph nodes in the right and left lower quadrants consistent with mesenteric panniculitis (Figure 2). The patient was treated with prednisone and Tamoxifen with resolution of symptoms. PET-CT and colonoscopy were negative for concomitant malignancy. Tumor markers including CEA, CA 19-9, and AFP were within normal limits.Figure 1Figure 2Mesenteric panniculitis is a chronic, nonspecific fibrosing disorder of the adipose tissue of the intestinal mesentery. It can occur independently or in association with malignancy, vasculitis, or autoimmune disorders. While the majority of cases are asymptomatic, symptoms may include abdominal pain and asthenia. Obstructive symptoms and CT features of small bowel dilatation, like our case, are rare. While biopsy was previously required for diagnosis, CT and MRI are now acceptable modalities for diagnosis. Work up should include exclusion of associated malignancy. Although there is no standard therapy, treatment with steroids, Cyclophosphamide, and Tamoxifen among others, have been used. Surgical resection is performed in cases of intestinal obstruction. In conclusion, mesenteric panniculitis is a rare clinical entity that can occur independently or in association with other disorders. Diagnosis can be challenging, but features on cross sectional imaging can be highly suggestive of the disease. Associated malignancy should be excluded. Treatment with antiinflammatory and immunosuppressive agents can be successful with an overall good prognosis and rare recurrence.