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Case Report

Mesenteric panniculitis, a rare entity presenting as (sub)acute intestinal obstruction: a case report

Paudyal, Nabin MDa,; Shrestha, Bijaya MDb; Yadav, Deepak MDa

Author Information
IJS: Short Reports: July/September 2022 - Volume 7 - Issue 3 - p e56
doi: 10.1097/SR9.0000000000000056
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Abstract

Mesenteric panniculitis (MP) is a benign, acute/chronic fibrosing inflammatory disease affecting the adipose tissue of the mesentery1. Its estimated prevalence is <1% and has wide gastrointestinal manifestations. It was first recognized by Jura in 1924 (as retractile mesenteritis). Ogden et al in 1960 coined the term “mesenteric panniculitis”2–4. Kipfer et al5 included the disease as 1 of the 3 diseases with similar entities including MP, retractile mesenteritis and mesenteric lipodystrophy (broadly: sclerosing mesenteritis). MP appears to be more common in men (2–3:1)6. It can be associated with a variety of conditions like prior abdominal surgery, autoimmune diseases, malignancy, cholelithiasis, and infections. The disease often has nonspecific symptoms that may mislead a treating physician. Abdominal imaging is the mainstay of diagnosis with computerized tomography (CT) scan having the high sensitivity. Confirmation requires histopathologic examination7.

In this case report, we describe the presentation of a lady who presented with features suggestive of bowel obstruction. She was diagnosed with MP and managed with oral steroid therapy.

Methods

We report this case in line with the updated consensus-based surgical case report (SCARE) guidelines8.

Case report

A 79-year-old lady, Asian by ethnicity and housewife by occupation presented to the emergency of our hospital in March 2021. She presented with complaints of diffuse abdominal pain, 3 episodes of vomiting and nausea. Abdominal pain was acute, without any definite character and radiation, aggravated on changing position in bed and associated with vomiting. Vomiting was nonprojectile, nonblood mixed. She had no history of fever. She had past medical history of heart failure with reduced ejection fraction (35%) and had undergone angioplasty in December 2020. She also had hypertension and diabetes. Her medications included oral Atorvastatin (20 mg), Clopidogrel (75 mg), Aspirin (75 mg), Amlodipine (5 mg), Metformin (500 mg), Voglibose (0.3 mg), and Glimepiride (2 mg). She had no history of substance abuse. No significant family, socioeconomic or travel history were present. Her vitals at the time of examination were a temperature of 98 (on a Fahrenheit scale), blood pressure of 130/80 mm of mercury, a pulse of 85 beats per minute and respiratory rate of 24 breaths per minute. On physical examination, she was dehydrated. On per abdominal examination, the abdomen was laxed and tenderness was present over the left lumbar and iliac fossa on deep palpation. On auscultation bowel sounds were sluggish. On digital rectal examination, no impacted stools and bloodstains were present.

Initial workup revealed the following laboratory parameters:

-
Test Results Reference Value
Hemoglobin (g/dl) 12.1 g/dL 12–15
White blood counts (10×3/µL) 11.6/mm3 4–10
Platelets 165,000/mm3 40,00–10,000
Bilirubin (total) 0.7 mg/dL 0.2–1.0
AST 19 U/L 14–63
ALT 15 U/L 15–37
Amylase 37 U/L 25–115
Random blood glucose 335 mg/dL 50–130
Serum sodium 137 mg/dl 135–145
Serum potassium 4.0 mmol/L 3.5–5.0
ALT indicates Alanine transaminase; AST, Aspartate transaminase.

X-ray abdomen in erect and supine view showed dilated small bowel loops. Ultrasound of the abdomen revealed moderate ascites in the peritoneal and pelvic cavity. It also revealed air and particulate matter filled prominent large bowel loops and fluid-filled prominent small bowel loops with sluggish peristalsis (suggestive of intestinal obstruction). X-ray is shown in Figures 1 and 2.

F1
Figure 1:
X-ray abdomen and pelvis taken in supine view showing dilated small bowel loops.
F2
Figure 2:
Erect x-ray of abdomen and pelvis showing dilated bowl loops with stool content.

A provisional diagnosis of (sub)acute intestinal obstruction was made. She was admitted to the ICU (considering her a high-risk case). Our differential diagnosis included ischemic colitis and diabetic gastroparesis. The patient was kept nil per oral (NPO) and nasogastric tube on free drainage was placed. She was started on IV antibiotics, PPIs, and analgesics. Insulin therapy was started in view of uncontrolled diabetes even with 3 oral hypoglycemic agents.

The patient reported no decrease in pain intensity even until the next day. A Contrast enhanced computed tomography scan of the abdomen and pelvis was done. It revealed heterogenous and increased attenuation of mesenteric fat on the left paracolic gutter suggestive of panniculitis. It also revealed presence of few enlarged mesenteric lymph nodes with mild ascites. The common bile duct was dilated (14 mm) with smooth tapering at the ampulla of Vater. There was no evidence of cholelithiasis in CT (Figs. 3, 4).

F3
Figure 3:
Cross section of abdomen at the level of L1/L2 vertebral body. Arrow showing evidence of increased attenuation of mesenteric fat at left paracolic and pericolic gutter.
F4
Figure 4:
Coronal computed tomography of the abdomen showing multiple dilated and thickened bowel loops. Arrow shows increased mesenteric fat attenuation.

Based on the CT reports, a diagnosis of MP was made. Antinuclear antibodies were normal. The patient was started on 40 mg of oral prednisolone daily. Two days following therapy the patient showed marked improvement in her abdominal symptoms. She was shifted from ICU to general surgery ward on the fourth day. She was discharged on the fifth day of hospital admission uneventfully on oral steroid therapy for 2 weeks. Her follow-up visit 2 weeks later was also normal. The steroid was tapered gradually over the next 1 week.

Discussion

MP is a nonspecific pathologic condition that most commonly affects adipose tissue of small and large intestine. Histologically, the MP has chronic inflammation, necrosis of the adipose tissue and fibrotic change. The components reflect the different phases of the natural course of a single disease. MP may present as an incidental finding (asymptomatic) or present with wide range of symptoms like abdominal pain, abdominal mass, vomiting, and weight loss. This case is the first of its kind in our center. Our patient presented with abdominal pain and vomiting. Also, as the disease incidence is <1% with male predominance and our patient is a lady, the case imposed a diagnostic challenge to our team. Symptom duration of MP may vary from 24 hours up to 2 years9. In our case the patient presented to the emergency department after 48 hours from the starting of pain.

CT scan is the image if choice; however, it does not confirm the disease. The diagnosis is confirmed only on histology. Since obtaining a biopsy sample is an invasive procedure, this decision should be tailored to the patient considering the risks versus benefits of obtaining a biopsy. It was not done in our case as our patient is an elderly lady with multiple comorbidities. It is important that we do a thorough workup should we suspect other conditions that mimic the clinical and CT scan signs of MP1.

The objective of the treatment in a case of MP is alleviation of the symptoms. In asymptomatic cases, no treatment is required. Moreover, patients without any symptoms remain symptom free during follow up too. In symptomatic cases, treatment may not always prevent complications, but improves the majority of presenting complaints. In patients showing symptoms suggestive of bowel obstruction or mesenteric vessels thrombosis leading to necrosis, chemotherapy as well as radiotherapy are considered effective. Particularly, steroids and tamoxifen have been shown to very effective in management of severe inflammation10. Cases with bowel-obstructive symptoms or vasculo-occlusive symptoms may require surgical management. Although a follow up CT scan is not mandatory, it can be done to determine resolution or recurrence. In our case, patient had resolution of symptoms 48 hours after starting the steroid therapy. She was not subjected to repeat CT scan. Her 2 weeks follow-up was uneventful the timeline of events is outlined in (Figure 5).

F5
Figure 5:
Timeline of events.

Conclusion

We here describe a case report of MP in a Nepalese lady. We initially directed our management along the lines of (sub)acute intestinal obstruction due to lack of awareness of the disease. MP should also be considered as a differential diagnosis when features of bowel obstruction are present. Use of corticosteroids is associated with rapid improvement of symptoms. Biopsy may not be indicated in all cases showing improvement.

Ethical approval

Ethical approval was taken from the Institutional Review Committee (IRC) before the submission of the case report.

Source of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

D.Y.: supervision. N.P. and B.S.: writing original draft; writing-review and editing. N.P.: referencing.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

None.

Guarantor

Nabin Paudyal.

Acknowledgments

None.

References

1. Mehta P, Reddivari AKR, Ahmad M. A case report of mesenteric panniculitis. Cureus 2020.12. https://doi.org/10.7759/CUREUS.6764.
2. Roberts FM, Nielsen OF. Retractile mesenteritis. Am J Dig Dis 1964;9:231–5.
3. Ogden WW, Bradburn DM, Rives JD. Pannicultis of the mesentery. Ann Surg 1960;151:659–68.
4. Wexner SD, Attiyeh FF. Mesenteric panniculitis of the sigmoid colon—report of two cases. Dis Colon Rectum 1987;30:812–5.
5. Kipfer RE, Moertel CG, Dahlin DC. Mesenteric lipodystrophy. Ann Intern Med 1974;80:582–8.
6. Issa I, Baydoun H. Mesenteric panniculitis: various presentations and treatment regimens. World J Gastroenterol 2009;15:3827.
7. Kaya C, Bozkurt E, Yazici P, et al. Approach to the diagnosis and treatment of mesenteric panniculitis from the surgical point of view. Turk J Surg 2018;34:121.
8. Agha RA, Franchi T, Sohrabi C, et al. The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines. Int J Surg 2020;84:226–30.
9. Kgomo M, Elnagar A, Mashoshoe K. Case report: mesenteric panniculitis. BMJ Case Rep 2017:2017. https://doi.org/10.1136/BCR-2017-220910.
10. Green MS, Chhabra R, Goyal H. Sclerosing mesenteritis: a comprehensive clinical review. Ann Transl Med 2018;6:336.
Keywords:

Intestinal obstruction; Mesenteric panniculitis; Steroids

Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of IJS Publishing Group Ltd.