Sclerosing Mesenteritis: Clinical Presentation, Imaging Findings, and Treatment

Abstract

A 67-year old male with a history of myocardial infarction status post percutaneous coronary intervention and stage IV bladder cancer status post radical cystoprostatectomy with ileal neobladder reconstruction and chemotherapy (cisplatin and gemcitabine) presented with progressive, severe epigastric and lower abdominal pain associated with nausea. The pain had intensified over the previous week and was associated with a recent fifteen pound weight loss in the setting of poor oral intake. He denied nausea or diarrhea.His physical exam was notable for abdominal tympany and tenderness. His labs were notable for mild hyperkalemia (potassium 5.0 mmol/L), normal white blood cell count, lipase of 28 U/L, normal liver function tests, and positive 2+ leukocyte esterase and 1+ blood in his urine. Upper endoscopy showed a small Schatzki's ring in the distal third of the esophagus with small hiatal hernia and gastritis. On CT, there was thickened, indurated mesentery and a mesenteric mass (Figure 1) with abdominal lymphadenopathy and a new adrenal nodule. EPIDEMIOLOGY & CLINICAL PRESENTATIONSclerosing mesenteritis, also known as mesenteric panniculitis, is part of a spectrum of idiopathic primary inflammatory and fibrotic processes that affect the mesentery and is characterized by inflammation of mesenteric fat. Although its etiology is unclear, it has been associated with previous abdominal surgery, autoimmunity, paraneoplastic syndromes, ischemic injury, and infection. Sclerosing mesenteritis is also associated with a high prevalence of coexisting malignancies and future cancer development. 1 In a study evaluating 7620 patients presenting with a chief complaint of abdominal pain, the prevalence was 0.6%. 2 The presentation of sclerosing mesenteritis is variable. In a series of 68 patients with sclerosing mesenteritis, 75% had abdominal pain, 26% had nausea/vomiting, 20% had anorexia and weight loss, and 20% had altered bowel habits. 3 In an 84-patient cohort, only 35% had abdominal pain, and 20% had an incidental abdominal mass on exam. 2 The duration of symptoms ranged from 24 hours to 2 years. 2 Up to 20% of patients with sclerosing mesenteritis develop complications, often intestinal obstruction from mass effect. 3 Other complications include mesenteric vascular occlusion, chylous ascites, and adverse effects from medications used to treat sclerosing mesenteritis.