Mesenteric panniculitis (MP) is a rare disease, which was first named and classified as chronic and benign by Ogden in 1960 and 1965. It is defined as a chronic inflammation of the fatty tissue of the mesentery root that can extend to the entire mesentery and retroperitoneum. It can be presented as mesenteric masses of fatty tissue hard to enucleate, yellowish and with white stains (areas of superficial retraction). Fibrosis and retraction can occur, pushing and pulling neighbour structures like the stomach, small bowel and colon, or widening the duodenal arch.
Mesenteric panniculitis is a chronic inflammation and fibrosis of the fatty tissue of the mesentery root, with unknown etiology.
I found an interesting report of two cases of MP published in 1980 by Prof. Dr. Carlos M. Costa Almeida from the ancient and well functioning Centro Hospitalar de Coimbra (Covões). Is there anything new since then? This was my immediate question.
The two cases published 38 years ago corresponded to two male patients complaining of epigastric pain and vomiting in one case, and the second of abdominal pain and polyarthralgias.
Physical examination was normal. In the first case an upper gastrointestinal contrast film revealed a widening of the duodenal arch setting an inverted 3-image (pancreas neoplasia?), and in the second case a contrast enema showed a pushed colon with extrinsic compression in the descending portion (lymphoma?). No other imaging exams were available at that time. Both patients were operated based on these data (can you imagine this today?), and mesenteric panniculitis was found. Fatty tissue masses were biopsied, and no other procedure was performed. Patients were discharge home.
According to the authors, this entity may be a part of a group of diseases: retroperitoneal fibrosis, Rydel's thyroiditis, sclerosing cholangitis, pseudo-tumour of the orbit and idiopathic fibrosis of the mediastinum. Additionally they stated 38ys ago that the etiology may be similar to the Ormond's Syndrome (retroperitoneal fibrosis), and it may be linked to the Weber-Christian disease (nodular subcutaneous panniculitis). Autoimmune disorders may be the reason and should be investigated. Is there any new information in the present day?
Cemal Kaya et al from Turkey published this year a paper about the diagnosis and treatment of MP. Definition is still the same: chronic inflammation and necrosis of the fatty tissue resulting in fibrosis. The exact cause of this disease is still unknown, but comorbidities like diabetes, hypertension, rheumatic diseases, and abdominal and pelvic malignancies have been reported. Cemal Kaya et al state that the most common diseases associated/causing MP are autoimmune disorders and malignancy. At is was said 38ys ago MP has a benign course and is considered not to be precancerous. However there are case reports of death caused by intense fibrosis resulting in bowel venous and lymphatic obstruction. Nowadays it is known that histologically there are three main components that define the different phases of the same disease: fat necrosis - mesenteric lipodistrophy; fibrosis - sclerosing mesenteritis; chronic inflammation - mesenteric panniculitis.
Autoimmune disorders and malignancies and the most common diseases associated with MP.
As it would be expected, signs and symptoms are the same. Abdominal pain is the most frequently presenting symptom, but nausea, vomiting, constipation, diarrhea, weight loss, and abdominal mass are also possible. How to diagnose? This is the most interesting and wonderful difference I found between these two papers according to clinical practice 38 years ago and now. In both papers ultrasonography (US) and CT scan (high specificity) are presented as good imaging tools, but both state that surgery in the best method to diagnose MP. From the 22 patients reported by the Turkish group (2018), none was submitted to surgery and was the CT scan that made the diagnosis. Thirty-eight years ago no CT scan or US were available in Coimbra, and the two patients were submitted to laparotomy based only in clinical evaluation and contrast abdominal films. Although this is unthinkable in the present time, that "ancient" medicine was "raw" medicine based in clinical signs and symptoms that most of us are now forgetting while looking "blindly" to imaging findings. You should always see, hear, and touch the patient before asking for exams.
CT scan is important for diagnosis.
Surgery still is the best option for diagnosis confirmation.
About the treatment... There is no consensus. If laparotomy is performed, Costa Almeida et al defend that resection of adipose tissue masses should only be tried in extreme cases with bowel obstruction. Otherwise, biopsy is the only procedure. Thirty-eight years ago there were no studies on steroids and analgesics efficacy. In fact, those studies are still lacking in 2018, although clinical improvement has been noted with steroids and immunosupressive therapy. Why there are no studies in 2018? Is there a small amount of cases to study? Is there no interest in investigating this disease?
Turning to Kaya et al, they state that the most frequent treatment approach consists of supportive measures, and that MP can be self-limited and regress even without medical treatment. They report 12 patients treated in an outpatient basis with anti-inflammatory drugs with good results and no complications. One treatment I do not understand is the antibiotherapy delivered by the turkish group to a group of patients treated in the surgery ward. If MP is a chronic inflammation and not an infection, why use them?
In the present day, supportive treatment is the best option.
MP has a benign course but can be life threatening.
Lastly, I would like to join together the last ideas from both papers. Firstly, and according to Costa Almeida et al, although MP has a benign course it must always be considered dangerous because fibrosis and retraction can cause bowel occlusion, venous and lymphatic obstruction and urethral stenosis. Secondly, Kaya et al advise all patients diagnosed with MP must be investigated for other diseases, particularly malignancies.
In conclusion, almost nothing has changed in the last 38 years...
Bibliography from 1980 (not available online):
Costa Almeida C, Rigueira R, Pacheco Mendes M, Dos Reis L. Paniculite mesentérica: revisão a propósito de dois casos. Coimbra Med 1980; 1(6): 403-409.
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by Dr. Carlos Eduardo Costa Almeida
General Surgeon