Understanding Mesenteric Panniculitis: Symptoms, Diagnosis, and Treatment

Mesenteric panniculitis is a rare condition affecting the mesentery, which supports and connects the intestines to the abdominal wall. The mesentery consists of smooth tissue called peritoneum, layered with adipose (fat) tissue for support and protection. When the mesentery becomes inflamed, it can lead to a range of symptoms that can be difficult to diagnose and manage. This article highlights the symptoms associated with mesenteric panniculitis, how it’s diagnosed, and treatment options.

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What is Mesenteric Panniculitis?

Mesenteric panniculitis affects approximately 1.5% of the population. It is twice as common in men than in women.  It occurs most often in people between the ages of 60-70. Given its rarity and the fact that it is a relatively new condition, mesenteric panniculitis is often misdiagnosed.

Mesenteric panniculitis is an inflammatory condition affecting the fat in the mesentery. Chronic inflammation of the mesentery can lead to significant pain and fibrosis, a condition called sclerosing mesenteritis. “Mesenteritis" refers to the inflammation of the mesentery, while "sclerosing" describes the process of scarring.
Some research suggests that mesenteric panniculitis and sclerosing mesenteritis are the same condition.

Other literature suggests that the term “sclerosing mesenteritis” is more characteristic of advanced stages involving fibrosis. Mesenteric panniculitis can often involve mesenteric edema as part of its inflammatory response. The inflammation in mesenteric panniculitis can lead to vascular permeability, which allows fluid to accumulate in the mesenteric tissues.

Symptoms and Clinical Presentation

The wide range of symptoms can make this condition difficult to diagnose. Common symptoms of mesenteric panniculitis may include:

• Abdominal pain, that may become chronic
• Abdominal bloating
• Nausea and vomiting
• Constipation or diarrhea
• Unintentional weight loss due to loss of appetite
• Fatigue 
• Fever

Causes and Risk Factors

The cause of mesenteric panniculitis is currently unknown. Some theories include autoimmune disease, post-abdominal surgery, infections, or neoplastic (cancer) conditions, especially lymphomas. Unfortunately, most evidence of an autoimmune connection lacks statistical significance. 

Other risk factors include conditions that cause chronic inflammation in the body, leading to progressive fibrosis, such as Sjogren’s syndrome or Crohn’s disease.

Steps in the Diagnostic Process

Diagnosing mesenteric panniculitis can be difficult as its symptoms are commonly found in other abdominal conditions. A thorough medical history and physical examination are typically the first steps. Depending on the findings, blood tests and imaging tests may be ordered.

Here's a general approach to diagnosing mesenteric panniculitis:

Step 1: Patient History: 

A comprehensive evaluation that includes all pertinent medical history, family history of autoimmune conditions, and present symptoms helps to establish a clinical picture.

Step 2: Physical Exam

A physical exam may reveal abdominal tenderness or a palpable mass that could indicate fibrotic tissue. Ascites, or fluid accumulation in the abdomen, may also be observed. 

Unintentional weight loss or signs of systemic illness, such as fever or malaise, may be present.

Step 3: Blood Tests

There aren’t any specific labs used to diagnose mesenteric panniculitis. Routine labs, such as CBC and CMP, are usually within normal range. ANA or other specific autoimmune markers may be tested if there is a family history of autoimmune disease. Tumor markers may also be measured to exclude cancer if there is a concern about malignancies.

Blood tests that check for inflammation markers tend to be elevated with this condition. These include:

• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP)

Step 4: Additional Testing and Imaging

An ultrasound (US) can be used for the initial assessment of this condition as it offers real-time imaging, is noninvasive, and does not emit radiation. It can detect the appearance of a mass or area of fluid accumulation; however, it does not offer a detailed view of the mesenteric fat and connective tissues.

Mesenteric panniculitis can be seen more accurately on a Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI).  A CT scan is often the first choice for diagnosing mesenteric panniculitis. A CT scan of the abdomen shows characteristic thickening of the mesentery with signs of fat necrosis and fibrosis. This thickening can sometimes be particularly dense in one area and look like a mass. 

With mesenteric panniculitis, there can be lymphadenopathy (enlarged lymph nodes) in the mesentery and pelvic area, but blood vessels appear normal. This is referred to as a halo sign and helps to differentiate between mesenteric panniculitis and cancer. Misty mesentery sign is a term that refers to a mild presentation of inflammation found on a CT scan.

MRI is more useful for further evaluation, particularly if detailed soft tissue imaging is needed to assess the extent of the inflammation and fibrosis. MRI can better differentiate between the layers of the mesentery. For people who are sensitive to radiation or require repeat imaging, MRI is a preferable option since it does not use ionizing radiation, unlike CT scans.

Although biopsy is the gold standard for diagnosing mesenteric panniculitis, CT findings are usually sufficient to make a clinical diagnosis. Some research disagrees with this viewpoint, suggesting that surgical biopsy is required to fully exclude other conditions. 

The differential diagnoses include mesenteric neoplasms, such as lymphomas or tumors, that, despite showing a halo sign, may still require further diagnostic evaluation.

Treatment and Management

Treatment options for mesenteric panniculitis include medications, dietary and lifestyle modifications, and in some rare cases, surgery. Surgery is not curative and is only indicated in individuals who may have a bowel obstruction as a result of fibrotic tissue.

Medications:
Corticosteroids are often recommended as the initial treatment of choice for symptomatic individuals. According to one study, 40 mg of prednisolone is recommended for 2 weeks.
Other research suggests that infection-treating drugs and NSAIDs are effective for most patients. Some preliminary clinical trials show promising results for thalidomide and low-dose naltrexone (LDN), although more research is needed in this area.

Lifestyle Modifications and Supportive Care

• Nutrition that supports the inflammatory response may help to soothe the digestive system. A diet rich in whole foods and healthy sources of omega-3 fatty acids is important for reducing inflammation within the body. 

• It may be helpful to identify and reduce certain foods that may worsen symptoms, such as processed foods, or foods high in fat or spices. 

• Optimal hydration and consuming smaller meals may also ease digestion and reduce abdominal discomfort. 

• Incorporating mindfulness and relaxation techniques can help lower stress, which can aggravate symptoms. 

• Keeping a journal of symptoms, dietary intake, and triggers can be beneficial to managing mesenteric panniculitis. 

Regular follow-ups with your healthcare provider are recommended to monitor this condition and adjust treatment as necessary.

Patient Education and Support

Living with mesenteric panniculitis can be challenging as the condition’s symptoms can vary between individuals. In addition to medical treatments, alternative therapies such as yoga, mindfulness, or acupuncture may help manage chronic pain by reducing stress and improving physical discomfort. 

Individuals may benefit from joining support groups or online communities to connect with others who share their experiences. NORD, the National Organization for Rare Disorders, may offer a good starting point for connecting with individuals living with mesenteric panniculitis. This organization offers resources and support groups to help patients and caregivers manage rare conditions.

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Key Takeaways

• Mesenteric panniculitis is a rare and often misdiagnosed condition with variable symptoms, including abdominal pain, bloating, nausea, and weight loss. Diagnosis is challenging due to the overlap with other abdominal conditions, requiring a thorough evaluation through patient history, physical examination, and imaging studies like CT or MRI.
  
• The exact cause of mesenteric panniculitis is not well understood but may involve autoimmune diseases, previous abdominal surgery, infections, or neoplastic conditions like lymphomas. Genetic predisposition and environmental triggers might also play a role.
  
• Mesenteric panniculitis is generally not considered life-threatening. Many individuals have mild to moderate symptoms that are self-limiting. However, when the inflammation is present, it can cause considerable discomfort that can interfere with one’s quality of life. Understanding its symptoms and treatment options is needed to ensure effective care.