- Lawrence S Friedman, MD
Lawrence S Friedman, MD
- Section Editor — General Gastroenterology
- Professor of Medicine
- Harvard Medical School
- Tufts University School of Medicine
- Darrell Pardi, MD, MS
Darrell Pardi, MD, MS
- Professor of Medicine
- Vice Chair, Division of Gastroenterology and Hepatology
- Associate Dean, Mayo
Sclerosing mesenteritis is a rare, non-neoplastic inflammatory and fibrotic disease that affects the mesentery. Sclerosing mesenteritis can affect the integrity of the gastrointestinal lumen and mesenteric vessels by a mass effect. Sclerosing mesenteritis can result in a variety of gastrointestinal and systemic manifestations, including abdominal pain, nausea and vomiting, diarrhea, weight loss, and fever [1-4]. This topic will review the epidemiology, etiology, clinical manifestations, diagnosis, and management of sclerosing mesenteritis.
Sclerosing mesenteritis is often used as an umbrella term for a spectrum of idiopathic primary inflammatory and fibrotic processes that affect the mesentery [5,6]. Several terms have been used to describe this process based on the degree of inflammation and fibrosis, these include mesenteric lipodystrophy (with a predominance of fat necrosis) and sclerosing mesenteritis or mesenteric fibrosis (with a predominance of fibrosis) (table 1). Patients usually have a range of pathologic findings, with varying components of inflammation, fibrosis, and fat necrosis, although usually one feature predominates at a given time. Histologic progression has only rarely been documented . It is quite likely that these features represent different points in the natural history of the underlying process, with adipocyte necrosis (mesenteric lipodystrophy) evolving into a chronic inflammatory state (mesenteric panniculitis), and finally to fibrosis (sclerosing mesenteritis).
Sclerosing mesenteritis appears to be rare, and a significant proportion of patients are asymptomatic. In one autopsy series, the prevalence of sclerosing mesenteritis was one percent . In a prospective evaluation of over 7000 consecutive abdominal computed tomography examinations, the prevalence of sclerosing mesenteritis was 0.6 percent . Most patients in this study were Caucasian. Although sclerosing mesenteritis has been reported in persons as young as three years of age, it is diagnosed most commonly in the fifth to seventh decades of life, with a median age of 65 years [10,11]. The low prevalence in childhood and adolescence may be attributable to a smaller amount of mesenteric fat . While most studies have found that the prevalence of sclerosing mesenteritis is higher in men, this has not been consistently demonstrated [6,9-11]
ETIOLOGY AND PATHOGENESIS
The pathogenesis of sclerosing mesenteritis remain unclear, although several mechanisms have been postulated.
●Abdominal surgery or abdominal trauma – It is hypothesized that sclerosing mesenteritis results in genetically predisposed individuals who have abnormal responses to healing and repair of connective tissue in response to trauma [6,13]. In a systematic review of the published literature, previous abdominal surgery or abdominal trauma was described in almost 30 percent of patients . In one series of 92 patients with sclerosing mesenteritis, 38 patients (41 percent) had prior abdominal surgery, including cholecystectomy, appendectomy, hysterectomy, and colectomy . Sclerosing mesenteritis has been reported in association with both acute abdominal injury and chronic repetitive trauma (eg, pneumatic jackhammer) and inflammation (eg, occult ileal perforation) [14,15]. The use of powdered surgical gloves has also been implicated in the development of abdominal fibrosis as a precursor to sclerosing mesenteritis .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Durst AL, Freund H, Rosenmann E, Birnbaum D. Mesenteric panniculitis: review of the leterature and presentation of cases. Surgery 1977; 81:203.
- Kipfer RE, Moertel CG, Dahlin DC. Mesenteric lipodystrophy. Ann Intern Med 1974; 80:582.
- Monahan DW, Poston WK Jr, Brown GJ. Mesenteric panniculitis. South Med J 1989; 82:782.
- Parra-Davila E, McKenney MG, Sleeman D, et al. Mesenteric panniculitis: case report and literature review. Am Surg 1998; 64:768.
- Kelly JK, Hwang WS. Idiopathic retractile (sclerosing) mesenteritis and its differential diagnosis. Am J Surg Pathol 1989; 13:513.
- Emory TS, Monihan JM, Carr NJ, Sobin LH. Sclerosing mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy: a single entity? Am J Surg Pathol 1997; 21:392.
- OGDEN WW 2nd, BRADBURN DM, RIVES JD. MESENTERIC PANNICULITIS: REVIEW OF 27 CASES. Ann Surg 1965; 161:864.
- Khachaturian T, Hughes J. Mesenteric panniculitis. West J Med 1988; 148:700.
- Daskalogiannaki M, Voloudaki A, Prassopoulos P, et al. CT evaluation of mesenteric panniculitis: prevalence and associated diseases. AJR Am J Roentgenol 2000; 174:427.
- Akram S, Pardi DS, Schaffner JA, Smyrk TC. Sclerosing mesenteritis: clinical features, treatment, and outcome in ninety-two patients. Clin Gastroenterol Hepatol 2007; 5:589.
- Sharma P, Yadav S, Needham CM, Feuerstadt P. Sclerosing mesenteritis: a systematic review of 192 cases. Clin J Gastroenterol 2017; 10:103.
- Adams JT. Abdominal wall, omentum, mesentry, and retroperitoneum. In: Principles of Surgery, 6th ed, Schwartz S, Shires F, Spencer F (Eds), McGraw Hill, New York 1994. p.1485.
- Jura V. Sulla mesenterite retratile e sclerosante. Policlinico (Sez. Chir.) 1924; 31:575.
- van der Hulst RW, Rauws EA, Tytgat GN. Mesenteritis secondary to the use of a pneumatic jackhammer. Eur J Gastroenterol Hepatol 1995; 7:573.
- Mathew J, McKenna F, Mason J, et al. Sclerosing mesenteritis with occult ileal perforation: report of a case simulating extensive intra-abdominal malignancy. Dis Colon Rectum 2004; 47:1974.
- Horton KM, Lawler LP, Fishman EK. CT findings in sclerosing mesenteritis (panniculitis): spectrum of disease. Radiographics 2003; 23:1561.
- Papadaki HA, Kouroumalis EA, Stefanaki K, et al. Retractile mesenteritis presenting as fever of unknown origin and autoimmune haemolytic anaemia. Digestion 2000; 61:145.
- Vidarsson B, Matthíasson P, Agnarsson BA, Onundarson PT. Mesenteric panniculitis presenting with autoimmune haemolytic anaemia. Acta Haematol 2002; 107:35.
- Vernace MA, Bellucci AG, Mossey RT, et al. Minimal change nephropathy associated with sclerosing mesenteritis. Nephron 1996; 73:473.
- Dor AM, Kohler JL, Aubrespy P, et al. [Mesenteric panniculitis, an unusual initial stage of acute lupus erythematosus in a ten-year old girl (author's transl)]. Arch Anat Cytol Pathol 1982; 30:121.
- Sauvaget F, Piette JC, Galezowski N, et al. [Relapsing polychondritis and mesenteric panniculitis: apropos of 2 cases]. Rev Med Interne 1993; 14:253.
- Arroyo-Ávila M, Vilá LM. Limited systemic sclerosis initially presenting with mesenteric panniculitis. BMJ Case Rep 2014; 2014.
- Garrido A, Verdejo C, Márquez JL, et al. [Intestinal lymphoma and mesenteric panniculitis: complications of undiagnosed celiac disease]. Gastroenterol Hepatol 2008; 31:221.
- Bala A, Coderre SP, Johnson DR, Nayak V. Treatment of sclerosing mesenteritis with corticosteroids and azathioprine. Can J Gastroenterol 2001; 15:533.
- Bush RW, Hammar SP Jr, Rudolph RH. Sclerosing mesenteritis. Response to cyclophosphamide. Arch Intern Med 1986; 146:503.
- Généreau T, Bellin MF, Wechsler B, et al. Demonstration of efficacy of combining corticosteroids and colchicine in two patients with idiopathic sclerosing mesenteritis. Dig Dis Sci 1996; 41:684.
- Kikiros CS, Edis AJ. Mesenteric panniculitis resulting in bowel obstruction: response to steroids. Aust N Z J Surg 1989; 59:287.
- Tytgat GN, Roozendaal K, Winter W, Esseveld MR. Successful treatment of a patient with retractile mesenteritis with prednisone and azathioprine. Gastroenterology 1980; 79:352.
- Pardi, DS, Rochester, MN, 2017, personal communication.
- Scheer F, Spunar P, Wiggermann P, et al. Mesenteric Panniculitis (MP) in CT - A Predictor of Malignancy? Rofo 2016; 188:926.
- Goh J, Otridge B, Brady H, et al. Aggressive multiple myeloma presenting as mesenteric panniculitis. Am J Gastroenterol 2001; 96:238.
- Gögebakan Ö, Albrecht T, Osterhoff MA, Reimann A. Is mesenteric panniculitis truely a paraneoplastic phenomenon? A matched pair analysis. Eur J Radiol 2013; 82:1853.
- TEDESCHI CG, BOTTA GC. Retractile mesenteritis. N Engl J Med 1962; 266:1035.
- Hirano H, Yoshida A, Sasae Y, et al. Mesenteric panniculitis: a rare cause of fever. Int J Rheum Dis 2012; 15:e40.
- Harris RJ, van Stolk RU, Church JM, Kavuru MS. Thoracic mesothelioma associated with abdominal mesenteric panniculitis. Am J Gastroenterol 1994; 89:2240.
- Medina-Franco H, Listinsky C, Mel Wilcox C, et al. Concomitant sclerosing mesenteritis and bile duct fibrosis simulating Klatskin's tumor. J Gastrointest Surg 2001; 5:658.
- Sans M, Varas M, Anglada A, et al. Mesenteric panniculitis presenting as fever of unknown origin. Am J Gastroenterol 1995; 90:1159.
- Höring E, Hingerl T, Hens K, et al. Protein-losing enteropathy: first manifestation of sclerosing mesenteritis. Eur J Gastroenterol Hepatol 1995; 7:481.
- Hinds BR, Bahrami S, Bernardi JM, Callen JP. Cutaneous sclerosis: a previously undescribed manifestation of sclerosing mesenteritis. Arch Dermatol 2010; 146:1009.
- Rispo A, Sica M, Bucci L, et al. Protein-loosing enteropathy in sclerosing mesenteritis. Eur Rev Med Pharmacol Sci 2015; 19:477.
- Ginsburg PM, Ehrenpreis ED. A pilot study of thalidomide for patients with symptomatic mesenteric panniculitis. Aliment Pharmacol Ther 2002; 16:2115.
- Pérez-Fontán FJ, Soler R, Sanchez J, et al. Retractile mesenteritis involving the colon: barium enema, sonographic, and CT findings. AJR Am J Roentgenol 1986; 147:937.
- Sato M, Ishida H, Konno K, et al. Mesenteric panniculitis: sonographic findings. Abdom Imaging 2000; 25:142.
- Weiser J, Salky B, Slepian A, Dikman S. Laparoscopic diagnosis of retractile mesenteritis. Gastrointest Endosc 1992; 38:615.
- Sabaté JM, Torrubia S, Maideu J, et al. Sclerosing mesenteritis: imaging findings in 17 patients. AJR Am J Roentgenol 1999; 172:625.
- Sheth S, Horton KM, Garland MR, Fishman EK. Mesenteric neoplasms: CT appearances of primary and secondary tumors and differential diagnosis. Radiographics 2003; 23:457.
- Valls C. Fat-ring sign in sclerosing mesenteritis. AJR Am J Roentgenol 2000; 174:259.
- Okino Y, Kiyosue H, Mori H, et al. Root of the small-bowel mesentery: correlative anatomy and CT features of pathologic conditions. Radiographics 2001; 21:1475.
- Badet N, Sailley N, Briquez C, et al. Mesenteric panniculitis: still an ambiguous condition. Diagn Interv Imaging 2015; 96:251.
- van Putte-Katier N, van Bommel EF, Elgersma OE, Hendriksz TR. Mesenteric panniculitis: prevalence, clinicoradiological presentation and 5-year follow-up. Br J Radiol 2014; 87:20140451.
- Lawler LP, McCarthy DM, Fishman EK, Hruban R. Sclerosing mesenteritis: depiction by multidetector CT and three-dimensional volume rendering. AJR Am J Roentgenol 2002; 178:97.
- Seo M, Okada M, Okina S, et al. Mesenteric panniculitis of the colon with obstruction of the inferior mesenteric vein: report of a case. Dis Colon Rectum 2001; 44:885.
- Mindelzun RE, Jeffrey RB Jr, Lane MJ, Silverman PM. The misty mesentery on CT: differential diagnosis. AJR Am J Roentgenol 1996; 167:61.
- Seo BK, Ha HK, Kim AY, et al. Segmental misty mesentery: analysis of CT features and primary causes. Radiology 2003; 226:86.
- Ghanem N, Pache G, Bley T, et al. MR findings in a rare case of sclerosing mesenteritis of the mesocolon. J Magn Reson Imaging 2005; 21:632.
- Kobayashi S, Takeda K, Tanaka N, et al. Mesenteric panniculitis: MR findings. J Comput Assist Tomogr 1993; 17:500.
- Fujiyoshi F, Ichinari N, Kajiya Y, et al. Retractile mesenteritis: small-bowel radiography, CT, and MR imaging. AJR Am J Roentgenol 1997; 169:791.
- Kronthal AJ, Kang YS, Fishman EK, et al. MR imaging in sclerosing mesenteritis. AJR Am J Roentgenol 1991; 156:517.
- Zissin R, Metser U, Hain D, Even-Sapir E. Mesenteric panniculitis in oncologic patients: PET-CT findings. Br J Radiol 2006; 79:37.
- Nguyen BD. F-18 FDG PET demonstration of sclerosing mesenteritis. Clin Nucl Med 2003; 28:670.
- Montgomery E, Torbenson MS, Kaushal M, et al. Beta-catenin immunohistochemistry separates mesenteric fibromatosis from gastrointestinal stromal tumor and sclerosing mesenteritis. Am J Surg Pathol 2002; 26:1296.
- Ehrenpreis ED, Roginsky G, Gore RM. Clinical significance of mesenteric panniculitis-like abnormalities on abdominal computerized tomography in patients with malignant neoplasms. World J Gastroenterol 2016; 22:10601.
- McCrystal DJ, O'Loughlin BS, Samaratunga H. Mesenteric panniculitis: a mimic of malignancy. Aust N Z J Surg 1998; 68:237.
- Phillips RH, Carr RA, Preston R, et al. Sclerosing mesenteritis involving the pancreas: two cases of a rare cause of abdominal mass mimicking malignancy. Eur J Gastroenterol Hepatol 1999; 11:1323.
- Wilkinson JM, Nyamekye I, Reed MW, Polacarz S. Advanced gastrointestinal malignancy or benign inflammatory disease? An unusual presentation of sclerosing mesenteritis. Report of a case. Dis Colon Rectum 1994; 37:1155.
- Gilfrich CP, D'Elia G, Black P, et al. Retractile mesenteritis mimicking an adrenal tumor. J Urol 1999; 162:1677.
- Sheikh RA, Prindiville TP, Arenson D, Ruebner BH. Sclerosing mesenteritis seen clinically as pancreatic pseudotumor: two cases and a review. Pancreas 1999; 18:316.
- Coulier B. Mesenteric panniculitis. Part 2: prevalence and natural course: MDCT prospective study. JBR-BTR 2011; 94:241.
- Daumas A, Agostini S, Villeret J, et al. Spontaneous resolution of severe, symptomatic mesocolic panniculitis: a case report. BMC Gastroenterol 2012; 12:59.
- Soergel KH, Hensley GT. Fatal mesenteric panniculitis. Gastroenterology 1966; 51:529.
- Han SY, Koehler RE, Keller FS, et al. Retractile mesenteritis involving the colon: pathologic and radiologic correlation (case report). AJR Am J Roentgenol 1986; 147:268.
- Pallette EM, Pallette EC, Harrington RW. Sclerosing lipogranulomatosis: its several abdominal syndromes. Arch Surg 1967; 94:803.
- Guest S. Tamoxifen therapy for encapsulating peritoneal sclerosis: mechanism of action and update on clinical experiences. Perit Dial Int 2009; 29:252.
- Mazure R, Fernandez Marty P, Niveloni S, et al. Successful treatment of retractile mesenteritis with oral progesterone. Gastroenterology 1998; 114:1313.
- Venkataramani A, Behling CA, Lyche KD. Sclerosing mesenteritis: an unusual cause of abdominal pain in an HIV-positive patient. Am J Gastroenterol 1997; 92:1059.
- Iwanicki-Caron I, Savoye G, Legros JR, et al. Successful management of symptoms of steroid-dependent mesenteric panniculitis with colchicine. Dig Dis Sci 2006; 51:1245.
- ETIOLOGY AND PATHOGENESIS
- CLINICAL PRESENTATION
- Clinical features
- Laboratory findings
- Incidental imaging findings
- General approach
- Diagnostic imaging
- DIFFERENTIAL DIAGNOSIS
- NATURAL HISTORY
- APPROACH TO MANAGEMENT
- Whom to treat
- Pre-treatment considerations
- Obstructive symptoms
- Non-obstructive symptoms
- - Initial treatment
- - Monitoring response to treatment
- - Duration of therapy in responders
- - Alternative approaches and refractory disease
- SUMMARY AND RECOMMENDATIONS