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Abdominal Pain From Sclerosing Mesenteritis
Image of the Month Abdominal Pain From Sclerosing Mesenteritis CHRISTOPHER G. P. HILLEMAND,* ROSEMARY CLARKE,‡ and SEAMUS J. MURPHY* *Department of Medicine, Southern HSC Trust, Daisy Hill Hospital, Newry; ‡Department of Pathology, Southern HSC Trust, Craigavon Area Hospital, Portadown, Northern Ireland
A
67-year-old man with insulin-dependent diabetes mellitus, asthma, irritable bowel syndrome, and temporal arteritis was admitted after an episode of hypoglycemia. He described persistent vomiting, intermittent constipation, abdominal pain, and low back pain for several months. There was a palpable mass in the left hypochondrium. Investigation results including full blood picture, urea and electrolyte levels, amylase level, liver function test results, and tumor marker levels (carcinoembryonic antigen and carbohydrate antigen 19-9) were normal. Creactive protein level was increased at 103 mg/L (normal range, 0 –5). Abdominal ultrasound was normal. Computed tomography (CT) showed an ill-defined mass (5.6 ⫻ 3.5 cm) in the small-bowel mesentery to the left of midline (Figure A). CT– guided biopsy was unsuitable because of overlying bowel. At laparotomy a 12 ⫻ 12 ⫻ 6 cm mobile mass with a smooth surface was found in the left upper quadrant within the small-bowel mesentery, and a biopsy was performed. Histopathology showed prominent fatty tissue transected by bands of fibrous tissue with inflammation characterized by prominent eosinophils (Figures B and C). No malignancy or lymphoma was identified. A diagnosis of sclerosing mesenteritis was made. Sclerosing mesenteritis is a fibroinflammatory condition of unknown etiology that primarily affects the small-bowel mesentery.1 It is rare, with an autopsy series reporting a prevalence of 1%2 and a radiology series describing a prevalence of 0.6% in more than 7000 abdominal CT scans.3 It usually affects men between the ages of 50 and 80. Symptoms are varied, with abdominal pain, nausea and vomiting, diarrhea, weight loss, and fever common. Common clinical findings are a palpable abdominal mass (usually in the left upper quadrant), abdominal tenderness, and abdominal distension. Laboratory findings are often normal, although nonspecific abnormalities, such as anemia and hypoalbuminemia, may be found. Inflammatory markers (erythrocyte sedimentation rate and C-reactive protein) may be increased and can be used to monitor response to medical therapy.4 Imaging of the abdomen with CT is the most sensitive diagnostic test, with the most common finding a soft-tissue mass in
the small-bowel mesentery. This finding, however, is nonspecific, and surgical biopsy invariably is required to confirm the diagnosis and exclude other conditions such as lymphoma, carcinoid syndrome, and peritoneal carcinomatosis. Treatment is empiric, and patients often do not require any treatment. In this case (and in the majority of cases), surgical resection was impossible because the mass extended to the root of the mesentery and thus compromised the blood supply of the small bowel. Surgical bypass should be considered in patients whose symptoms are caused predominantly by intestinal obstruction. A number of medications have been used to treat this condition and have been reported in small case series. Corticosteroids in combination with tamoxifen is the preferred first-line therapy.5 Other treatment modalities that have been studied include azathioprine, cyclophosphamide, and thalidomide. References 1. Emory TS, Monihan JM, Carr NJ, et al. Sclerosing mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy: a single entity? Am J Surg Pathol 1997;21:392–398. 2. Khachaturian T, Hughes J. Mesenteric panniculitis. West J Med 1988;148:700. 3. Daskalogiannaki M, Voloudaki A, Prassopoulos P, et al. CT evaluation of mesenteric panniculitis: prevalence and associated diseases. AJR Am J Roentgenol 2000;174:427. 4. Ginsburg PM, Ehrenpreis ED. A pilot study of thalidomide for patients with symptomatic mesenteric panniculitis. Aliment Pharmacol Ther 2002;16:2115. 5. Akram S, Darrell S, Schaffner J, et al. Sclerosing mesenteritis: clinical features, treatment and outcome in 92 patients. Clin Gastroenterol Hepatol 2007;5:589 –596.
Conflicts of interest The authors disclose no conflicts. © 2011 by the AGA Institute 1542-3565/$36.00 doi:10.1016/j.cgh.2010.09.012 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:xxii
A
67-year-old man with insulin-dependent diabetes mellitus, asthma, irritable bowel syndrome, and temporal arteritis was admitted after an episode of hypoglycemia. He described persistent vomiting, intermittent constipation, abdominal pain, and low back pain for several months. There was a palpable mass in the left hypochondrium. Investigation results including full blood picture, urea and electrolyte levels, amylase level, liver function test results, and tumor marker levels (carcinoembryonic antigen and carbohydrate antigen 19-9) were normal. Creactive protein level was increased at 103 mg/L (normal range, 0 –5). Abdominal ultrasound was normal. Computed tomography (CT) showed an ill-defined mass (5.6 ⫻ 3.5 cm) in the small-bowel mesentery to the left of midline (Figure A). CT– guided biopsy was unsuitable because of overlying bowel. At laparotomy a 12 ⫻ 12 ⫻ 6 cm mobile mass with a smooth surface was found in the left upper quadrant within the small-bowel mesentery, and a biopsy was performed. Histopathology showed prominent fatty tissue transected by bands of fibrous tissue with inflammation characterized by prominent eosinophils (Figures B and C). No malignancy or lymphoma was identified. A diagnosis of sclerosing mesenteritis was made. Sclerosing mesenteritis is a fibroinflammatory condition of unknown etiology that primarily affects the small-bowel mesentery.1 It is rare, with an autopsy series reporting a prevalence of 1%2 and a radiology series describing a prevalence of 0.6% in more than 7000 abdominal CT scans.3 It usually affects men between the ages of 50 and 80. Symptoms are varied, with abdominal pain, nausea and vomiting, diarrhea, weight loss, and fever common. Common clinical findings are a palpable abdominal mass (usually in the left upper quadrant), abdominal tenderness, and abdominal distension. Laboratory findings are often normal, although nonspecific abnormalities, such as anemia and hypoalbuminemia, may be found. Inflammatory markers (erythrocyte sedimentation rate and C-reactive protein) may be increased and can be used to monitor response to medical therapy.4 Imaging of the abdomen with CT is the most sensitive diagnostic test, with the most common finding a soft-tissue mass in
the small-bowel mesentery. This finding, however, is nonspecific, and surgical biopsy invariably is required to confirm the diagnosis and exclude other conditions such as lymphoma, carcinoid syndrome, and peritoneal carcinomatosis. Treatment is empiric, and patients often do not require any treatment. In this case (and in the majority of cases), surgical resection was impossible because the mass extended to the root of the mesentery and thus compromised the blood supply of the small bowel. Surgical bypass should be considered in patients whose symptoms are caused predominantly by intestinal obstruction. A number of medications have been used to treat this condition and have been reported in small case series. Corticosteroids in combination with tamoxifen is the preferred first-line therapy.5 Other treatment modalities that have been studied include azathioprine, cyclophosphamide, and thalidomide. References 1. Emory TS, Monihan JM, Carr NJ, et al. Sclerosing mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy: a single entity? Am J Surg Pathol 1997;21:392–398. 2. Khachaturian T, Hughes J. Mesenteric panniculitis. West J Med 1988;148:700. 3. Daskalogiannaki M, Voloudaki A, Prassopoulos P, et al. CT evaluation of mesenteric panniculitis: prevalence and associated diseases. AJR Am J Roentgenol 2000;174:427. 4. Ginsburg PM, Ehrenpreis ED. A pilot study of thalidomide for patients with symptomatic mesenteric panniculitis. Aliment Pharmacol Ther 2002;16:2115. 5. Akram S, Darrell S, Schaffner J, et al. Sclerosing mesenteritis: clinical features, treatment and outcome in 92 patients. Clin Gastroenterol Hepatol 2007;5:589 –596.
Conflicts of interest The authors disclose no conflicts. © 2011 by the AGA Institute 1542-3565/$36.00 doi:10.1016/j.cgh.2010.09.012 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:xxii