Sclerosing mesenteritis
Updates to Article Attributes
Sclerosing mesenteritis, also referred to as mesenteric panniculitis orretractile mesenteritis, is an uncommon idiopathic disorder characterised by chronic non-specific inflammation involving the adipose tissue of the bowel mesentery. If is often considered in the spectrum of autoimmune disease 21.
Epidemiology
Typically this condition afflicts adults in their sixties with mild male predilection, although reports vary 1,2,4.
Associations
Numerous associated conditions have been variably described including 1,4:
- malignancy
- systemic lymphoma 1,20 (up to 10% risk of developing lymphoma)
- lung cancer 20
- melanoma 20
- colon cancer 20
- renal cancer 20
- myeloma 20
- gastric carcinoma 4,20
- recent abdominal surgery 4
- systemic inflammatory conditions
- autoimmune conditions (may be related to IgG4-related disease)
- may be related to Weber-Christian disease 2
There is debate about the association between systemic inflammatory conditions and mesenteric panniculitis. Determining causation is difficult. The term "secondary mesenteric panniculitis" is reserved by some authors for patients with systemic inflammatory conditions. Most authors would not use the term when there is a local cause for mesenteric inflammation.
Clinical presentation
Clinical presentation can be variable with fever and abdominal pain common 20, intestinal obstruction or ischaemia, a mass, or diarrhoea may also be present ref. Altered bowel habits and weight loss may be present in some cases ref. Occasionally, intermittent partial bowel obstruction is encountered 2. A firm left upper quadrant / central abdominal mass may be felt 2. In some situations sclerosing mesenteritis is asymptomatic.
Pathology
The small bowel mesentery is affected in most cases although the sigmoid mesocolon and omentum can also occasionally be involved.
The disease is said to pass through three stages, although some authors believe these to be separate entities 4:
- mesenteric lipodystrophy: degeneration of mesenteric fat
- mesenteric panniculitis: inflammatory reaction
- retractile mesenteritis / sclerosing mesenteritis: fibrosis, which may be associated with distortion or lymphatic obstruction
Macroscopic appearance
Macroscopically, the mesentery is thickened with either solitary or multiple focal masses 4.
Histology
Histology demonstrates 1:
- lipid-laden macrophages (mesenteric lipodystrophy)
- lymphocytic aggregates and lymphoid follicles (mesenteric panniculitis)
- variable amounts of fibrosis (retractile mesenteritis)
Radiographic features
Ultrasound
Ultrasound typically demonstrates distortion and thickening of the root of the mesentery with a slight increase in echogenicity. Mass effect may be evident 3. A halo of sparing around vessels may be also seen on ultrasound as a region of hypoechoic fat 3. Colour Doppler interrogation may show non-deviated mesenteric vessels within the mass 17.
CT
CT features are somewhat dependent on the main tissue component and include:
- well-demarcated or ill-defined mesenteric mass-like lesion with surrounding "misty" attenuation
- "misty" soft-tissue attenuation
The mesentery demonstrates mass effect and may have a ground glass opacity (misty mesentery). Typically the traversing mesenteric vessels and soft tissue nodules have a spared fat halo (this has sometimes been referred to as the fat ring sign). Its orientation is aligned with the root of the jejunal mesentery. Punctate/coarse calcifications (~20%), as well as small lymph nodes (usually <5 mm), may be present within the region.
Sometimes the Coulier crtieria are used on CT 8 ; which are
- sign1: the presence of a well-defined "mass effect" on neighbouring structures
- sign 2: constituted by mesenteric fat tissue of inhomogeneous higher attenuation than adjacent retroperitoneal or meso-colonic fat
- sign 3: containing small soft tissue nodes
- sign 4: may typically be surrounded by a hypo-attenuated fatty "halo sign"
- sign 5: hyperattenuating pseudocapsule may also surround the all entity
The last two signs are considered inconstant but very specific.
MRI
Findings are similar to CT. One report described a fibrous capsule around the inflammation 12.
Nuclear medicine
FDG PET-CT
May have high accuracy for the differentiation between
- sclerosing mesenteritis (or one of its stages): not FDG-avid
- malignant mesenteric involvement: FDG-avid
especially in patients with lymphoma 10. If in doubt, biopsy may be indicated in selected patients, even in asymptomatic lesions 11.
Treatment and prognosis
The mainstay of treatment is supportive, as the disease is typically self-limiting. If severe or protracted medical therapy with corticosteroids, cyclophosphamide or azathioprine can be contemplated 2. Mesenteric panniculitis cannot be completely resected and surgery is of no benefit. In up to 15% of cases, local lymphoma eventually develops 2,4. Some authors suggest associated malignancy rate of approximately 56% 16.
History and etymology
It was first described by Jura in 1924 as “retractile mesenteritis” and further labelled as “mesenteric panniculitis” by Odgen later in the 1960s.
Differential diagnosis
General imaging differential considerations include:
- mesenteric carcinoid tumour
- mesenteric lymphadenopathy due to malignancy:
- lymphoma
- colorectal carcinoma
- carcinoid
- metastatic disease
- mesenteric lymphadenopathy due to inflammation:
- appendicitis
- colonic diverticulitis
- cholecystitis
- pancreatitis
- systemic illness
- mesenteric lipoma: especially if large and if there are lymph nodes within it
- intraperitoneal focal fat infarction
-<p><strong>Sclerosing mesenteritis</strong>, also referred to as <strong>mesenteric panniculitis </strong>or<strong> </strong><strong>re</strong><strong>tractile mesenteritis</strong>, is an uncommon idiopathic disorder characterised by chronic non-specific inflammation involving the adipose tissue of the bowel <a href="/articles/mesentery">mesentery</a>.</p><h4>Epidemiology </h4><p>Typically this condition afflicts adults in their sixties with mild male predilection, although reports vary <sup>1,2,4</sup>.</p><h5>Associations</h5><p>Numerous associated conditions have been variably described including <sup>1,4</sup>:</p><ul>- +<p><strong>Sclerosing mesenteritis</strong>, also referred to as <strong>mesenteric panniculitis </strong>or<strong> </strong><strong>re</strong><strong>tractile mesenteritis</strong>, is an uncommon idiopathic disorder characterised by chronic non-specific inflammation involving the adipose tissue of the bowel <a href="/articles/mesentery">mesentery</a>. If is often considered in the spectrum of autoimmune disease <sup>21</sup>.</p><h4>Epidemiology </h4><p>Typically this condition afflicts adults in their sixties with mild male predilection, although reports vary <sup>1,2,4</sup>.</p><h5>Associations</h5><p>Numerous associated conditions have been variably described including <sup>1,4</sup>:</p><ul>
-</ul><p>The mesentery demonstrates mass effect and may have a ground glass opacity (<a href="/articles/misty-mesentery-sign-2">misty mesentery</a>). Typically the traversing mesenteric vessels and soft tissue nodules have a spared fat halo (this has sometimes been referred to as the <a href="/articles/fat-ring-sign-mesenteric-panniculitis">fat ring sign</a>). Its orientation is aligned with the root of the jejunal <a href="/articles/mesentery">mesentery</a>. Punctate/coarse calcifications (~20%), as well as small lymph nodes (usually <5 mm), may be present within the region.</p><h5>MRI</h5><p>Findings are similar to CT. One report described a fibrous capsule around the inflammation <sup>12</sup>.</p><h5>Nuclear medicine</h5><h6>FDG PET-CT</h6><p>May have high accuracy for the differentiation between</p><ul>- +</ul><p>The mesentery demonstrates mass effect and may have a ground glass opacity (<a href="/articles/misty-mesentery-sign-2">misty mesentery</a>). Typically the traversing mesenteric vessels and soft tissue nodules have a spared fat halo (this has sometimes been referred to as the <a href="/articles/fat-ring-sign-mesenteric-panniculitis">fat ring sign</a>). Its orientation is aligned with the root of the jejunal <a href="/articles/mesentery">mesentery</a>. Punctate/coarse calcifications (~20%), as well as small lymph nodes (usually <5 mm), may be present within the region.</p><p>Sometimes the <strong>Coulier crtieria</strong> are used on CT <sup>8 </sup>; which are</p><ul>
- +<li>
- +<strong>sign1</strong>: the presence of a well-defined "mass effect" on neighbouring structures </li>
- +<li>
- +<strong>sign 2</strong>: constituted by mesenteric fat tissue of inhomogeneous higher attenuation than adjacent retroperitoneal or meso-colonic fat </li>
- +<li>
- +<strong>sign 3</strong>: containing small soft tissue nodes </li>
- +<li>
- +<strong>sign 4</strong>: may typically be surrounded by a hypo-attenuated fatty "halo sign" </li>
- +<li>
- +<strong>sign 5</strong>: hyperattenuating pseudocapsule may also surround the all entity </li>
- +</ul><p>The last two signs are considered inconstant but very specific.</p><h5>MRI</h5><p>Findings are similar to CT. One report described a fibrous capsule around the inflammation <sup>12</sup>.</p><h5>Nuclear medicine</h5><h6>FDG PET-CT</h6><p>May have high accuracy for the differentiation between</p><ul>
-<li>carcinoid</li>- +<li><a title="carcinoid" href="/articles/carcinoid">carcinoid</a></li>
References changed:
- 20. Kaya C, Bozkurt E, Yazıcı P, İdiz U, Tanal M, Mihmanlı M. Approach to the Diagnosis and Treatment of Mesenteric Panniculitis from the Surgical Point of View. Turk J Surg. 2018;34(2):121-4. <a href="https://doi.org/10.5152/turkjsurg.2018.3881">doi:10.5152/turkjsurg.2018.3881</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30023976">Pubmed</a>
- 21. Ehrenpreis E, Roginsky G, Gore R. Clinical Significance of Mesenteric Panniculitis-Like Abnormalities on Abdominal Computerized Tomography in Patients with Malignant Neoplasms. World J Gastroenterol. 2016;22(48):10601-8. <a href="https://doi.org/10.3748/wjg.v22.i48.10601">doi:10.3748/wjg.v22.i48.10601</a>
- 20. Issa I, Baydoun H. Mesenteric panniculitis: various presentations and treatment regimens. (2009) World journal of gastroenterology. 15 (30): 3827-30. <a href="https://doi.org/10.3748/wjg.15.3827">doi:10.3748/wjg.15.3827</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/19673029">Pubmed</a> <span class="ref_v4"></span>
Image 19 CT (non-contrast) ( update )
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