A rare case report of immunoglobulin G4-related sclerosing mesenteritis and review of the literature.

INTRODUCTION: Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a rare autoimmune disorder involving 1 or multiple organs, most commonly the pancreas, lacrimal glands, and salivary glands. However, IgG4-related sclerosing mesenteritis (SM) involving the small-bowel mesentery is rare. Given that IgG4-related SM usually mimics the imaging characteristics of mesenteric malignancies, its preoperative diagnosis remains challenging. In addition, no specific consensus has been reached regarding the treatment of IgG4-related SM. Therefore, a better understanding of the characteristics, treatment, and prognosis of IgG-related SM is urgently needed. Herein, we report a rare case of IgG-related SM. PATIENT CONCERNS: A 67-year-old man was admitted to our hospital after incidental detection of an abdominal mass on ultrasound imaging, although he reported being generally well. The findings on triple-phase abdominal computed tomography were highly consistent with a malignant mesenteric tumor. DIAGNOSES: The hallmark histopathological features along with elevated levels of IgG4 (145 mg/dL) and imaging findings were indicative of IgG-related SM. INTERVENTIONS: The patient was treated surgically. Postoperative histopathological examinations exhibited tissue infiltration with lymphocytes and IgG4-positive plasma cells, as well as fibrosis. OUTCOMES: Ten days after surgery, the patient was discharged from the hospital, and did not show any clinical sign of IgG-related SM within 1-year follow-up. CONCLUSION: This case highlights the mesentery as an uncommon site of involvement as well as how early IgG-related SM can be completely asymptomatic. Thus, this study has advanced our knowledge of IgG-related SM and may improve treatments for similar conditions.

Sclerosing Mesenteritis Mimicking IgG4-related Disease.

A 72-year-old man was followed as an outpatient at our hospital for 6 years after surgery for small cell carcinoma of left adrenal gland origin. Follow-up abdominal computed tomography showed a 6-cm mass in the left lower mesentery. The patient underwent open laparotomy. The histological diagnosis was sclerosing mesenteritis. The previous specimens of the left adrenal mass were then re-examined with a microscope, and panniculitis was found around the small cell carcinoma. Both lesions were histologically similar to IgG4-related disease (RD), but they did not completely meet the diagnostic criteria of IgG4-RD clinically or histologically.

Mesenteric panniculitis.

A 53-year-old black woman presented with a 3-day history of abdominal pain. Ultrasound of the abdomen showed a gall bladder packed with small stones. She gave a history of abdominal surgery for a gynaecological condition. She had a cholecystectomy done, but her symptoms continued after cholecystectomy. She then had anendoscopic retrograde cholangiopancreatogram (ERCP) and sphincterotomy done, again her symptoms remained the same. A CT scan of the abdomen was done, and mesenteric panniculitis was suspected. A laparoscopic biopsy of the mesentery was performed, and it confirmed mesenteric panniculitis. She was started on a 2-week course of steroids to which she responded very well. Three months after the initial presentation, she was still asymptomatic.

Sclerosing mesenteritis mimicking metachronous peritoneal metastases from descending colon adenocarcinoma.

BACKGROUND: Sclerosing mesenteritis is a non-neoplastic inflammatory disease that occurs in the bowel mesentery. Distinguishing sclerosing mesenteritis from neoplasms may be difficult because of the clinical and radiographic similarities between the two disease entities. CASE PRESENTATION: We report a case of sclerosing mesenteritis mimicking peritoneal metastases of colorectal carcinoma. A 73-year-old man with stage II descending colon adenocarcinoma with poor prognostic features was found to have developed left lower abdominal quadrant masses on computed tomography (CT) 9 months after undergoing radical surgery. These masses were diagnosed as peritoneal metastases because they grew in size and displayed fluorodeoxyglucose (FDG) uptake 3 months later; thus, a laparotomy was performed. The masses, which were localized in the jejunal mesentery, were excised completely via segmental jejunal resection. Histopathological analysis confirmed that the masses were sclerosing mesenteritis. The patient showed no signs of sclerosing mesenteritis or colorectal carcinoma recurrence during follow-up. CONCLUSIONS: In patients suspected of having localized peritoneal metastasis from malignancies, any masses must be sampled by surgical excisional biopsy and subsequently examined to rule out alternative diagnoses, such as sclerosing mesenteritis.

[An analysis of clinical characteristics of twelve cases of mesenteric panniculitis].

Objective: Mesenteric panniculitis is an idiopathic, uncommon disease involving the adipose tissue of mesentery. The etiology, diagnosis and treatment are still unnoticed. We thus reported a case series to improve the understanding of this rare disorder. Methods: We retrospectively analyzed the clinical data of 12 patients with mesenteric panniculitis including manifestation, diagnosis, treatment and prognosis. Results: We found a male predominance (M∶F 3∶1) with the median age of 58 years old at diagnosis. The most common symptom was abdominal pain (9/12), followed by abdominal distension (3/12) and weight loss (3/12). Physical examination was unremarkable in the majority of patients (8/12). C reactive protein (9/12) and erythrocyte sedimentation rate (10/12) were normal in majority of patients. CT findings were of much diagnostic value. All patients had small intestinal mesentery involvement and multi-nodular appearance with increased fat density. Pseudo-capsule sign (8/12) and fat halo sign (6/12) were common. Pathological diagnosis was obtained in 4 cases showing fat tissue inflammation with local necrosis and fibrosis. Six cases all received prednisone, 2 with combined cyclophosphamide, 1 with azathioprine, 1 with tripterygium wilfordii. Short-term clinical response was achieved in all cases, but two patients relapsed. Conclusions: Mesenteric panniculitis occurs predominantly in middle-aged and elderly. Abdominal pain is the leading symptom. Inflammatory markers are often normal while computed tomography is the most important diagnostic tool. Surgery combined with cortical steroid and immunosuppressant agents is effective.

Mesenteric panniculitis, a rare cause of acute surgical abdomen in children. Case report and literature review.

Mesenteric panniculitis appears as a less known benign condition due to its infrequency and not fully elucidated etiology; currently, less than 20 cases in children have been reported. It is characterized by a fibrotic and inflammatory transformation of the mesentery fat of the small intestine and, less commonly, of the colon. The 8-year-old patient whose case we report presented in our Service complaining of acute digestive symptoms. A causality relation with the small yet frequent injuries the child suffered at the abdominal level during his sports practice may be hypothesized, although this correlation cannot be proven. Laboratory test values are usually within the normal range in such patients, yet the inflammatory values are sometimes high, just as in our case. The imagistic diagnostic workup detected a solid mass at the level of the hepatic colic flexure, with a non-homogenous structure, with fine contrast uptake in the walls; perilesional fatty infiltration with "misty mesentery" appearance; infracentimetric adenopathies located in the mesentery root. The tumor was surgically excised and intestinal anastomosis was performed. Achieving the final pathological diagnosis of mesenteric panniculitis was a difficult task, as it required several differential diagnoses, by ruling out a local vasculitis process and an idiopathic inflammatory Crohn's-like disease. The patient's post-operative evolution was positive. The follow-up examinations at one month, six months, one year and two years showed a good general condition, a good nutrition state and clinical-paraclinical test results within normal values. A significant association of mesenteric panniculitis to other malignancies, as well as a predisposition of these patients to the subsequent occurrence of neoplasms has been noted in adults. As these findings have not yet been proven in children, due to the small number of cases and the absence of prospective studies, long-term monitoring is an absolute must.

Sclerosing Mesenteritis Presenting as a Pseudotumor of the Greater Omentum.

OBJECTIVE: The aim was to demonstrate a diagnostic challenge of sclerosing mesenteritis initially considered as liposarcoma. CLINICAL PRESENTATION AND INTERVENTION: A 45-year-old man was admitted with a painful abdominal mass. Abdominal computed tomography demonstrated a well- demarcated tumor in his left hemiabdomen, with a large fat component and areas of soft tissue attenuation suggestive of liposarcoma. Intraoperative findings showed a tumor arising from the greater omentum. The tumor was completely removed, and histopathology confirmed a pseudotumorous type of sclerosing mesenteritis with dominant mesenteric lipodystrophy. CONCLUSION: This case showed that a pseudotumorous type of sclerosing mesenteritis should be considered in the differential diagnosis of the mesenteric tumors.

Extensive mesenteric lipodystrophy of the left colon: case report and brief review of the literature.

Mesenteric lipodystrophy is a rare inflammatory process that predominantly affects mesenteric adipose tissue of the small bowell. Several mechanisms have been suggested as responsible for this entity although the precise etiolog remains unknown. The diagnosis is based on CT or MRI imaging and generally confirmed by surgical biopsies. Treatment is individualized and empiric and depends on disease stage and symptoms. We report a case of a 35-year-old male who was admitted to our hospital with a history of abdominal pain, constipation and a palpable mass in the left lower quadrant. Abdominal CT scan showed diffuse thickening of the descending and rectosigmoid colon, associated with increased density of the mesenteric fat. After failure ofan initial treat- ment with glucocorticoids, he underwent a laparoscopic sigmoidectomy. Histopatholog analysis revealed extensive stea- tonecrosis ofpericolonicfat and lipid-ladenfoamy cells which was consistent with the diagnosis of mesenteric lipodystrophy. Clinical presentation and treatment as well as a brief review of the literature are discussed.

Sclerosing mesenteritis: A case of acute abdomen and intestinal obstruction.

Sclerosing mesenteritis (SM) is a rare idiopathic disorder characterized by chronic non-specific inflammation involving the adipose tissue of the bowel mesentery. It may be asymptomatic but it commonly presents with abdominal pain. Some individuals may have a palpable abdominal mass and affected individuals may develop small bowel obstruction or acute abdomen. We report a case of 27-year old man who presented to the Surgery Department at Chukwuemeka Odimegwu Ojukwu University Teaching Hospital (COOUTH), Amaku Awka, Anambra State with acute abdomen and intestinal obstruction. He subsequently, had a surgical resection, which was histologically confirmed as a sclerosing mesenteritis. Sclerosing mesenteritis is a rare disorder and this is the first case being reported in the literature from South-East, Nigeria.It is therefore, important to alert physicians, more especially the surgeons on the need to have a high index of suspicion in every case of intestinal obstruction.

A case of IgG4-related mesenteritis.

IgG4-related disease is a newly recognized fibroinflammatory condition characterized by tumefaction consisting of fibrosis with dense infiltration of IgG4-positive plasma cells; affecting various organs. A case of IgG4-related sclerosing mesenteritis is reported. A 64-year-old man was admitted to our hospital with a suspected tumor of the small intestine. Abdominal computed tomography demonstrated a 6-cm soft tissue mass in the right lower mesentery compressing the jejunum, which also showed accumulation of fluorodeoxyglucose uptake on fluorine-18 fluorodeoxyglucose positron emission tomography. With a preoperative diagnosis of suspected malignant lymphoma with lymphadenopathy in the mesentery, partial small bowel resection was performed. Macroscopically, a hard mass, including several swollen lymph nodes, was detected in the mesentery. Microscopically, marked fibrosis showing partially storiform pattern, obstructive phlebitis, follicular hyperplasia, and abundant infiltration of IgG4-positive plasma cells were detected. IgG4-related mesenteritis was diagnosed histopathologically, but the serum IgG4 level was 81 mg/dl postoperatively. Five months after the surgery, an 11-cm soft tissue mass involving the left ureter appeared. Histological examination of a biopsy specimen from the retroperitoneal mass showed fibrosis with inflammatory infiltration. Although IgG4-related retroperitoneal fibrosis could not be confirmed histologically, the tumor responded well to steroid therapy.

Sclerosing mesenteritis as a rare cause of upper ileus.

INTRODUCTION: Sclerosing mesenteritis is a rare pathological entity characterized by non-specific tumor-like expansion in mesentery. Accurate diagnosis of this disease is rarely made preoperatively. Surgery takes place in diagnosis, as well in treatment of the disease. We presented a case of sclerosing mesenteritis that affected the final portions of duodenum and initial part of jejunum with clinical picture of upper gastrointestinal obstruction. CASE REPORT: A 46-year-old man without previous medical history was presented with vomiting and loss of weight in the last 6 months. Due to suspicion of parapancreatic tumor by CT examination and clinical presentation of the disease, the patient underwent laparotomy. A mass infiltrated mesenteric root, initial part of superior mesenteric artery, the fourth duodenum portion and the ligament of Treitz, while the stomach and duodenum were dilatated. The intraoperative biopsy indicated a benign process. The mass was reduced with desobstruction of the duodenum. Definitively, histopathological finding showed fibromatosis in different phases of activity. Postoperative course passed without complications. The patient continued to receive an immunosuppressive drug therapy. After a 6-month treatment the patient showed no gastrointestinal problems. CONCLUSION: Sclerosing mesenteritis that affects the duodenum and the proximal part of the jejunum with subacute upper gastrointestinal obstruction is an extremely rare condition. In the presented case a surgical procedure was necessary for marking the diagnosis and treatment as well.

Uncommon solitary mesenteric mass: mesenteric panniculitis.

Mesenteric panniculitis is a rare, benign disease characterized by a chronic non-specific inflammatory process of mesenteric fat tissue with unknown etiology. Its clinical outcome ranges from complete resolution without any treatment to rapid progression culminating in death. So far, there is no established treatment available for its management. A 53-year-old female was admitted to our hospital because of intermittent abdominal pain, abdominal distension and early satiety for three months. Her abdominal CT scan revealed a solitary, well-defined, heterogeneous mass with a diameter of approximately 3.5cm x 2.8cm in the mesentery of small bowel. Exploratory laparotomy revealed yellowish-grey mass with a gritty consistency and histopathology of the resected specimen confirmed it to be mesenteric panniculitis. An increased awareness may lead to the use of a less invasive diagnostic approach and optimal management of this rare disease entity.

[Successful endoscopic transpapillary pancreaticobiliary drainage for omental panniculitis by hepatocellular carcinoma complicated by biliary fistula and pancreatic fistula].

A 78-year-old man with hepatocellular carcinoma treated by chemoembolization and percutaneous ethanol injection was admitted to our hospital because of acute abdomen. The CT scan showed biliary fistula caused by hepatocellular carcinoma protruding from S3. Endoscopic retrograde cholangiopancreatography showed disruption of an intrahepatic duct and the main pancreatic duct, and contrast agent leaked into the peritoneal cavity from each duct. Omental panniculitis with biliary fistula and pancreatic fistula was diagnosed. The symptoms improved by endoscopic nasobiliary drainage and endoscopic pancreatic stenting. On the 13th day after admission, we added endoscopic nasopancreatic drainage because his abdominal pain had been exacerbated by pancreatic juice leakage. Omental panniculitis by hepatocellular carcinoma complicated by biliary fistula and pancreatic fistula is extremely rare. Endoscopic transpapillary pancreaticobiliary drainage was effective for omental panniculitis in this case.

Spontaneous resolution of severe, symptomatic mesocolic panniculitis: a case report.

BACKGROUND: Mesenteric panniculitis is a rare chronic fibrosing inflammatory disease that typically affects the adipose tissue and mesentery of the small intestine but may also affect the mesosigmoid and the mesocolon. The pathology of this disease remains unclear despite association with some malignancies or inflammatory disorders. We report a case of mesocolic panniculitis and a literature review of its clinical presentation, imaging findings, associated conditions and treatment options. CASE PRESENTATION: A 64 year-old Caucasian man was admitted to the gastroenterology department for severe weakness, left lower quadrant abdominal pain, weight loss and diarrhoea. Physical examination revealed a palpable firm mass occupying the entire left part of the abdomen. Abdominal CT-scan showed fatty infiltration of the mesosigmoid and left mesocolic fat which was strongly suggestive of panniculitis. Laparoscopic surgery revealed an inflamed and edematous mesocolon and mesosigmoid; the sigmoid mucosa appeared petechial which was suggestive of venous ischemia. Histological examination of surgical biopsies revealed mesocolic panniculitis. Despite exhaustive investigation, no associated conditions were found and the cause was classified as idiopathic. Surprisingly, the patient clinically improved without therapeutic intervention other than supportive care. CONCLUSION: Although mesenteric panniculitis is most often a radiographic diagnosis without clinical symptomatology, it can also present with significant general status alteration. We report a case of mesocolic panniculitis complicated by development of an inflammatory mass associated with ischemic colitis. Mesenteric panniculitis is a difficult diagnosis to make which typically requires histologic confirmation. The overall prognosis is good with supportive treatment.

Mesenteric panniculitis patients requiring emergency surgery: report of three cases.

Mesenteric panniculitis is a rare, benign disease characterized by a chronic non-specific inflammatory process of mesenteric fat tissue with unknown etiology. The small bowel mesentery is affected mostly. This process rarely involves the large intestine mesentery. Mesenteric panniculitis includes symptoms as abdominal pain, nausea and vomiting, diarrhea, constipation, and fever. In our cases, we had difficulty in the preoperative diagnosis as the clinical changes imitated an obstruction or ischemia of the small bowel. All the cases required emergency abdominal surgery and partial jejunal resection. The aim of this article was to present three cases of mesenteric panniculitis of the small bowel mesentery requiring emergency surgery together with a short review of the literature.

Panniculectomy in preparation for renal transplantation: a new indication for an old procedure to reduce renal transplantation-associated wound complications.

End-stage renal disease patients who have lost a significant amount of weight are increasingly being evaluated for kidney transplantation. An abdominal panniculus, almost uniformly observed, creates an area predisposed to wound complications. Consequently, a panniculus may limit a patient's candidacy for transplantation. The authors describe their preliminary experience utilizing panniculectomy as a prophylactic procedure to reduce wound complications following kidney transplantation in patients whose panniculus would exclude them from renal transplantion. A single-institution chart review was conducted of nine patients with end-stage renal disease who underwent a panniculectomy in preparation for transplantation. Clinical outcomes and complications were reviewed. The nine patients included three men and six women with a mean age of 54.5 years and a mean body mass index of 28.3 kg/m. Four patients had diabetes. All patients underwent an uncomplicated panniculectomy, with a mean resected weight of 3.0 kg, and a mean length of hospital stay of 1.75 days. No one required blood transfusions. All patients were followed postoperatively for 3 months. Complications included an abscess and a skin dehiscence treated with local wound care. After recovery, patients were referred to the transplant center for re-evaluation for kidney transplantation. Thus far, four of these nine patients have undergone transplantation. This case series suggests that panniculectomy can be performed safely in patients with end-stage renal disease. Furthermore, panniculectomy gives these otherwise unsuitable kidney transplant candidates access to a life-saving operation.