Sclerosing mesenteritis is an uncommon idiopathic disorder characterised by chronic non-specific inflammation involving the adipose tissue of the bowel mesentery.
Typically this condition afflicts adults in their 60s with mild male predilection, although reports vary 1,2,4.
Often sclerosing mesenteritis is asymptomatic, but may present with nonspecific abdominal pain, altered bowel habits, and weight loss. Occasionally, intermittent partial bowel obstruction is encountered 2. A firm left upper quadrant / central abdominal mass may be felt 2.
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
Macroscopically, the mesentery is thickened with either solitary or multiple focal masses 4.
It may be related to Weber-Christian disease 2.
Histology demonstrates 1:
- lipid-laden macrophages (mesenteric lipodystrophy)
- lymphocytic aggregates and lymphoid follicles (mesenteric panniculitis)
- variable amounts of fibrosis (retractile mesenteritis)
Numerous associated conditions have been variably described including 1,4
- recent abdominal surgery 4
- systemic inflammatory conditions
- autoimmune conditions (may be related to IgG4-related disease)
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.
CT features are somewhat dependent on the main tissue component and include
- well-demarcated or ill-defined mesenteric masslike 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.
Ultrasound typically demonstrates distortion and thickening of the root of the mesentery with slight decrease in echogenicity. Mass effect may be evident. 3
A halo of sparing around vessels may be also seen on ultrasound as a region of hyperechoic fat 3.
Findings are similar to CT. One report describes a fibrous capsule around the inflammation 12.
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.
General imaging differential considerations include:
- mesenteric lymphadenopathy due to malignancy:
- mesenteric lymphadenopathy due to inflammation:
- mesenteric lipoma: especially if large and if there are lymphnodes within it
- 1. Daskalogiannaki M, Voloudaki A, Prassopoulos P et-al. CT evaluation of mesenteric panniculitis: prevalence and associated diseases. AJR Am J Roentgenol. 2000;174 (2): 427-31. AJR Am J Roentgenol (full text) - Pubmed citation
- 2. Doherty GM, Way LW. Current surgical diagnosis & treatment. McGraw-Hill Medical. (2006) ISBN:007142315X. Read it at Google Books - Find it at Amazon
- 3. Herlinger H, Maglinte DD, Birnbaum BA et-al. Clinical Imaging of the Small Intestine. Springer Verlag. (2001) ISBN:0387953884. Read it at Google Books - Find it at Amazon
- 4. Patel N, Saleeb SF, Teplick SK. General case of the day. Mesenteric panniculitis with extensive inflammatory involvement of the peritoneum and intraperitoneal structures. Radiographics. 19 (4): 1083-5. Radiographics (full text) - Pubmed citation
- 5. Jeong YJ, Kim S, Kwak SW et-al. Neoplastic and nonneoplastic conditions of serosal membrane origin: CT findings. Radiographics. 28 (3): 801-17. doi:10.1148/rg.283075082 - Pubmed citation
- 6. Lucey BC, Stuhlfaut JW, Soto JA. Mesenteric lymph nodes seen at imaging: causes and significance. Radiographics. 25 (2): 351-65. doi:10.1148/rg.252045108 - Pubmed citation
- 7. Coulier B. Mesenteric panniculitis. Part 2: prevalence and natural course: MDCT prospective study. JBR-BTR. 2012;94 (5): 241-6. Pubmed citation
- 8. Coulier B. Mesenteric panniculitis. Part 1: MDCT-pictorial review. JBR-BTR. 2012;94 (5): 229-40. Pubmed citation
- 9. Issa I, Baydoun H. Mesenteric panniculitis: various presentations and treatment regimens. World J. Gastroenterol. 2009;15 (30): 3827-30. Free text at pubmed - Pubmed citation
- 10. Zissin R, Metser U, Hain D et-al. Mesenteric panniculitis in oncologic patients: PET-CT findings. Br J Radiol. 2006;79 (937): 37-43. doi:10.1259/bjr/29320216 - Pubmed citation
- 11. Tamai Y et. al. A case of follicular lymphoma complicated with mesenteric panniculitis, Hematol Rev. Jul 1, 2009; 1(2): e17.
- 12. 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 (5): 632-6. doi:10.1002/jmri.20280 - Pubmed citation
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