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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 4  |  Issue : 2  |  Page : 264-266

Mesenteric panniculitis: A rare entity, report of two cases with review of the literature


Department of Pathology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

Date of Web Publication20-Dec-2016

Correspondence Address:
Kavita Mardi
Set No. 14, Type VI, IAS Colony, Meheli, Shimla - 171 009, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.196197

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  Abstract 

Mesenteric panniculitis is a rare, benign, and chronic fibrosing inflammatory disease that affects the adipose tissue of the mesentery of the small intestine and colon. Mesenteric panniculitis of the sigmoid colon is an extremely rare occurrence in surgical practice. The specific etiology of the disease is unknown. The diagnosis is suggested by computed tomography (CT) and is usually confirmed by surgical biopsies. Treatment is empirical and based on a few selected drugs. Surgical resection is sometimes attempted for definitive therapy although the surgical approach is often limited. We are reporting two cases of mesenteric panniculitis of the sigmoid colon, one of which was associated with carcinoma.

Keywords: Colon, computed tomography (CT), mesenteric panniculitis


How to cite this article:
Mardi K, Wahal SP. Mesenteric panniculitis: A rare entity, report of two cases with review of the literature. Arch Med Health Sci 2016;4:264-6

How to cite this URL:
Mardi K, Wahal SP. Mesenteric panniculitis: A rare entity, report of two cases with review of the literature. Arch Med Health Sci [serial online] 2016 [cited 2017 Jul 27];4:264-6. Available from: http://www.amhsjournal.org/text.asp?2016/4/2/264/196197


  Introduction Top


Mesenteric panniculitis is a rare, benign, and chronic fibrosing inflammatory disease that affects the adipose tissue of the mesentery of the small intestine and colon.[1],[2] The etiology and pathogenesis of the disease are very obscure. Various factors such as blunt abdominal trauma or prior surgery, infection, ischemia, autoimmune processes, and underlying malignancy have been suggested as possible causes. We present two cases of mesenteric panniculitis with review of the relevant literature.


  Case Reports Top


Case 1

A 59-year-old male was admitted to our hospital with history of generalized weakness, intermittent left lower quadrant abdominal pain, weight loss, constipation, and signs of partial bowel obstruction since 6 months. There was no history of fever, malena, or mucus in the stool. Physical examination revealed a palpable tender mass in the left abdomen. Computed tomography (CT) of the abdomen performed showed nodular soft tissue densities around the sigmoid junction. Malignancy was suspected and distal colectomy was performed. Grossly, a segment of the distal colon was received measuring 10 cm in length. On serosal aspect, overlying rectosigmoid junction, a well-demarcated single nodular lesion was seen measuring 4 × 4 cm. The cut surface was yellowish white, firm with few congested areas [Figure 1]. At a distance of 4 cm from this lesion was an ulceroinfiltrative growth in the sigmoid colon. Microscopic examination of sections from the serosal nodule demonstrated chronic reactive inflammatory process with proliferation of fibroblasts in the adipose tissue. Areas of steatonecrosis and lipid laden macrophages, few giant cells, lymphocytes, and plasma cells were present. Sections from the ulceroinfiltrative growth revealed features of well-differentiated adenocarcinoma. Based on these characteristic features, diagnosis of well-differentiated adenocarcinoma with mesenteric panniculitis was given.
Figure 1: Gross surgical specimen shows a 4-cm nodule in the mesentery with characteristic intensely yellow areas with congestion.

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Case 2

A 45-year-old man presented with pain in the epigastrium and umbilical region for 1 month. It was associated with intermittent nausea, fever, general malaise, and weight loss. On examination, he had low-grade fever, vague abdominal mass, and mild abdominal tenderness on superficial and deep palpations. Laboratory profile revealed a reduced hemoglobin, leukocytosis and raised erythrocyte sedimentation rate (ESR). CT scan revealed a solitary, well-defined mass composed of an extraluminal inhomogeneous fatty tissue with attenuation at the root of the mesocolon of the transverse colon. The mass was compressing the colonic lumen. On exploratory laparotomy, a hard area involving the mesocolon of the transverse colon was found adherent to the surrounding colon. The mesocolon and the adjacent colon were resected and sent for histopathological examination. Grossly, the mesocolon measured 15 × 13 × 5 cm. The hard mass measured 5 × 2.5 cm. The mesocolon was thickened with an irregular hard area of discoloration varying from tan brown to pale brown in color. Cut surface of the irregular mass was solid gray-white to gray-brown with few foci of hemorrhage. Microscopic examination revealed normal colonic mucosa, submucosa, and muscularis propria. Beyond the muscularis propria, there were lobules of mature adipose tissue separated by fibrous septae [Figure 2] and [Figure 3]. Blood vessels were also engulfed by the fibrous septae of variable thickness. At some places, the fibrous tissue formed sheets and was infiltrated by chronic inflammatory cells composed of lymphocytes and plasma cells. Occasional macrophages were also seen. A few foci of fat necrosis were also evident. A diagnosis of mesenteric panniculitis of the transverse mesocolon was given and the patient was kept on follow-up.
Figure 2: Lobules of the adipose tissue of the mesocolon separated with fibrous tissue infiltrated by chronic inflammatory cell infiltrate (hematoxylin and eosin, 40×).

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Figure 3: Muscularis propria of the colon engulfed by fibrous tissue infiltrated by chronic inflammatory cell infiltrate (hematoxylin and eosin, 40×).

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  Discussion Top


Mesenteric panniculitis is a rare inflammatory condition that is characterized by chronic and nonspecific inflammation of the adipose tissue of the intestinal mesentery. Only 150 cases have been reported in the literature so far This entity is also known as: Retractile mesenteritis, sclerosing mesenteritis, liposclerotic mesenteritis, isolated lipodystrophy of the mesentery, mesenteric lipomatosis, and lipogranuloma of the mesentery, and mesenteric manifestations of Weber-Christian disease.[1],[2] Incidence increases with age, and pediatric cases are exceptional, probably because children have less mesenteric fat when compared to adults.[3] The male-to-female ratio is 2-3:1.

The pathogenic mechanism of mesenteric panniculitis seems to be a nonspecific response to a wide variety of stimuli but the precise etiology remains unknown. Emory et al.[4] have reported a series in which 84% of the patients had a history of abdominal trauma or surgery. Furthermore, the disease is related to other factors such as mesenteric thrombosis, mesenteric arteriopathy, drugs, thermal or chemical injuries, vasculitis, avitaminosis, autoimmune disease, retained suture material, pancreatitis, bile or urine leakage, hypersensitivity reactions, and even bacterial infection.[2],[5] More recent studies have shown a strong relationship between tobacco consumption and panniculitis.[5] Retractile mesenteritis has been associated with a number of malignant diseases such as lymphoma, lung cancer, melanoma, colon cancer, renal cell cancer, myeloma, gastric carcinoma, chronic lymphocytic leukemia, Hodgkin's lymphoma, and a number of malignant diseases such as Renal cell carcinoma, carcinoid tumor, and thoracic mesothelioma.[3],[4],[5],[6]

In over 90% of the cases, mesenteric panniculitis involves the small-bowel mesentery although it may sometimes involve the sigmoid mesentery.[7] On rare occasions, it may involve the mesocolon, peripancreatic region, omentum, retroperitoneum, or pelvis.[6] The disease is often asymptomatic. The symptoms when present include anorexia, abdominal pain, abdominal fullness, nausea, pyrexia, and weight loss.[8] Presentations such as fever of unknown origin and protein-losing enteropathy have also been described. Laboratory parameters are frequently normal; however, an increased ESR has been noted.[6]

There are few cases of mesenteric panniculitis (MP) occurring concurrently with colorectal cancer and diverticulosis.[9] Daskalogianki et al.[5] have reported the coexistence of MP and various neoplastic diseases, especially lymphoma and gastrointestinal and urogenital adenocarcinomas of patients with MP. Association of MP and malignancy is indicated in the literature with 30% of patients with MP having an underlying malignancy.[3],[4]

Abdominal CT is an effective method for diagnostic evaluation. Two CT findings are considered somewhat specific for this disorder: A fat ring sign that reflects the preservation of fat around the mesenteric vessels, and the presence of a tumoral pseudocapsule, which is detected in 50% of the patients.[10] The definite diagnosis of mesenteric panniculitis is established by biopsy. Variable combinations of foci of fat degeneration and necrosis, a nonspecific and predominantly lymphocytic inflammatory infiltrate and fibrosis have been reported.[6] Based on the predominant histological findings, the disease has been called mesenteric lipodystrophy, mesenteric panniculitis, or sclerosing mesenteritis, according to the predominance of adiponecrosis, inflammation, or fibrosis, respectively.

The differential diagnosis of mesenteric panniculitis is broad and includes all disorders that can affect the mesentery. The most common are lymphoma, well-differentiated liposarcoma, peritoneal carcinomatosis, carcinoid tumor, retroperitoneal fibrosis, lipoma, mesenteric desmoid tumor, mesenteric inflammatory pseudotumor, mesenteric fibromatosis, and mesenteric edema.[11]

The course of mesenteric panniculitis is favorable in most cases [11] because the disease usually progresses slowly and subsides spontaneously. Nevertheless, in about 20% of the patients, it is associated with significant morbidity and a chronic debilitating course.[6] Conservative management includes corticosteroid therapy, tamoxifen, azathioprine, cyclophosphamide, oral progesterone, and thalidomide. Surgical resection is performed in cases of intestinal obstruction and other complications such as ischemia.[6] In both the cases reported in this article, the affected segment of the colon, along with the mesentery were removed by surgical intervention as the first case was found incidentally in a specimen resected for malignancy and the second case was diagnosed as malignancy radiologically. No further treatment was given in both the cases.


  Conclusion Top


In conclusion, mesenteric panniculitis should be considered in the differential diagnosis of patients with systemic manifestations and elevated markers of the acute phase response of unknown etiology, especially in the presence of abdominal symptoms. In these cases, the response to steroid therapy may be excellent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Grieser C, Denecke T, Langrehr J, Hamm B, Hänninen EL. Sclerosing mesenteritis as a rare cause of upper abdominal pain and digestive disorders. Acta Radiol 2008;49:744-6.  Back to cited text no. 1
    
2.
Gu GL, Wang SL, Wei XM, Ren L, Li DC, Zou FX. Sclerosing mesenteritis as a rare cause of abdominal pain and intraabdominal mass: A cases report and review of the literature. Cases J 2008;1:242.   Back to cited text no. 2
    
3.
Delgado Plasencia L, Rodríodra Ballester L, LL, L-Tomassetti Fernnsett EM, Hern ndez Morales A, Carrillo PallaréM A, HernHndez Siverio N. Mesenteric panniculitis: Experience in our center. Rev Esp Enferm Dig 2007;99:291-7.  Back to cited text no. 3
    
4.
Emory TS, Monihan JM, Carr NJ, Sobin LH. Sclerosing mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy: A single entity? Am J Surg Pathol 1997;21:392-8.  Back to cited text no. 4
    
5.
Daskalogiannaki M, Voloudaki A, Prassopoulos P, Magkanas E, Stefanaki K, Apostolaki E, et al. CT evaluation of mesenteric panniculitis: Prevalence and associated diseases. AJR Am J Roentgenol 2000;174:427-31.  Back to cited text no. 5
    
6.
Akram S, Pardi DS, Schaffner JA, Smyrk TC. Sclerosing mesenteritis: Clinical features, treatment, and outcome in ninety-two patients. Clin Gastroenterol Hepatol 2007;5: 589-96; quiz 523-4.  Back to cited text no. 6
    
7.
McCrystal DJ, O'Loughlin BS, Samaratunga H. Mesenteric panniculitis: A mimic of malignancy. Aust N Z J Surg 1998;68:237-9.  Back to cited text no. 7
    
8.
Shah AN, You CH. Mesenteric lipodystrophy presenting as an acute abdomen. South Med J 1982;75:1025-6.  Back to cited text no. 8
    
9.
Bak M. Nodular intra-abdominal panniculitis: An accompaniment of colorectal carcinoma and diverticular disease. Histopathology 1996;27:21-7.  Back to cited text no. 9
    
10.
Horton KM, Lawler LP, Fishman EK. CT findings in sclerosing mesenteritis (panniculitis): Spectrum of disease. Radiographics 2003;23:1561-7.  Back to cited text no. 10
    
11.
Piessen G, Mariette C, Triboulet JP. Mesenteric panniculitis. Ann Chir 2006;131:85-90.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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