Acute Epigastric Pain: Unexpected Urologic Findings on Computed Tomography.

Mesenteric panniculitis is a relatively common condition encountered on cross-sectional imaging and is mostly asymptomatic. We present one such case where an underlying malignancy was brought to forefront due to associated mesenteric panniculitis presenting as acute abdomen.

Bilateral pleural effusions as the first sign of mesenteric panniculitis.

A 38-year-old woman presented to the emergency department with a history of thoracic pain and anorexia for 1 week. Thoracic CT scan showed bilateral pleural effusion, a thoracentesis was performed revealing a transudate liquid with polymorphonuclears and predominance of eosinophils. After admission, the patient developed abdominal pain and the abdominal CT scan showed densification of the mesenteric fat characteristic of mesenteric panniculitis (MP). The patient went through investigation for secondary causes of panniculitis including infection, neoplasia and autoimmune diseases, and no abnormalities were found. The patient was treated with corticosteroids over a period of 3 months with complete resolution and without any signs of remission or secondary cause of MP. Moreover, the patient remained asymptomatic for 2 years after being discharged, which strengthens the diagnosis of MP that presented with eosinophilic pleural effusion.

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.

A severe case of sclerosing mesenteritis.

Sclerosing mesenteritis is a rare benign disease presenting with chronic inflammation of the mesenteric adipose tissue and variable degrees of fibrosis. A 47-year-old black man presented to the emergency department with symptoms of small bowel obstruction, requiring surgical treatment. The laparotomy revealed a stenosis of the distal ileum with mesenteric thickening and an enterectomy was performed. The postoperative period was complicated by the maintenance of bowel obstruction. The patient underwent a second laparotomy, in which the fibrosing process of the mesentery was much aggravated, and an ileo-colic resection was needed. After knowledge of the histological diagnosis, the patient was started on immunomodulators with clinical improvement. At 26 months of follow-up, patient is asymptomatic under medical treatment. This is the first report, to our knowledge, of a patient with progressive fibrosis in such short period of time requiring surgical re-intervention for bowel obstruction, owing to sclerosing mesenteritis.

[Immunoglobulin G4 Unrelated Idiopathic Mesenteric Sclerosis].

Sclerosing mesenteritis is a rare benign disease with a prevalence of 0.16-3.4% and is characterized by chronic nonspecific inflammation and extensive fibrosis in the adipose tissue of the mesentery although the exact pathogenesis is still elusive. A 65-year-old woman was referred with suspicion of an abdominal mass and biliary stones on abdominal ultrasonography and CT. Bile duct stones were confirmed by endoscopic ultrasonography and successfully treated by endoscopic retrograde cholangiography with stone removal. Furthermore, a 4.7 cm conglomerated mass on small intestinal mesentery was suspected as sclerosing mesenteritis based on the features on abdominal MRI. However, because it could not be differentiated from malignancy without histologic examination, laparoscopic excisional biopsy was performed; it showed only inflammatory cells with extensive fibrosis. Therefore, the abdominal mass was confirmed as sclerosing fibrosis and the patient was followed-up without any treatments because no mass-related symptoms accompanied the findings. Six months later, abdominal CT showed no significant change in the mass. Herein, we report a rare case of incidentally found idiopathic sclerosing mesenteritis.

An Autopsy Case of Mesenteric Panniculitis with Massive Pleural Effusions.

BACKGROUND Mesenteric panniculitis (MP) is an idiopathic chronic inflammatory condition of the mesentery. The main symptoms include abdominal pain, abdominal distention, weight loss, fever, nausea, and vomiting. The patients also present with chylous ascites in 14% of the cases and chylous pleural effusion (CPE) in very rare occasions. Despite the previous view of excellent prognosis of MP, two recent papers reported several fatal cases. However, there are still only a few autopsy case reports that describe the macroscopic and histological details of MP cases. CASE REPORT The patient was an 81-year-old Japanese woman. She complained of edema of her lower legs and face, general fatigue, and dyspnea. She was overweight and had type 2 diabetes (T2D). Computerized tomography (CT) demonstrated massive bilateral pleural effusions, with mild pericardial effusion and mild ascites. There was no pulmonary, cardiac or hepatic condition to explain the effusions. However, MP was suspected based on her CT. She gradually deteriorated into respiratory failure. The autopsy revealed CPEs (left 1,300 mL, right 1,400 mL) and MP in the mesentery of the small intestine. Neither neoplasia nor inflammatory conditions other than MP were detected. CONCLUSIONS In rare occasions, patients with MP present with CPE or chylothorax. We thought that a possible mechanism of the CPEs was a diaphragmatic defect. We suspected that being overweight and T2D had an etiological relationship with MP in our patient's case. Adipose tissue of the mesentery is the main focus of MP. We believed that MP would be the best umbrella term of the many synonyms.

Mesenteric Panniculitis-First Case Series After Bariatric Surgery.

Mesenteric panniculitis is an uncommon pathology, of poorly understood etiology, characterized by progressive inflammation and fibrosis of the small bowel mesentery. This disease has been reported usually after other abdominal surgeries. We present two cases of young male patients who underwent laparoscopic sleeve gastrectomy and developed abdominal symptoms within 45-60 days of surgery. Both were investigated for known post-bariatric complications. While first patient presented (5 months later) at an irreversible stage and died within 8-9 months of primary surgery, in second patient, the disease process could be reversed through early intervention, diagnosis, treatment, and compliance. Mesenteric panniculitis is a rapidly progressive entity, which can be adequately treated by early identification and long-term immune-suppressive therapy.

Sclerosing mesenteritis diagnosed with computed tomography and ultrasound-guided needle biopsy: the utility of the coaxial technique.

Here we report a case of sclerosing mesenteritis that we diagnosed with needle biopsy under the guidance of computed tomography (CT) and ultrasound (US) observation. An 82-year-old woman presented with appetite loss, weight loss and epigastric pain. CT of the abdomen and pelvis revealed increased density of the mesentery adjacent to the small bowel and enlarged lymph nodes. Sclerosing mesenteritis was suspected, but malignancies, such as lymphoma, were also considered. We performed CT and US-guided needle biopsy with the coaxial technique. An introducer needle was inserted, its correct location was documented with CT, and multiple specimens were taken with a finer needle passed through the introducer without incident. Adequate specimens were obtained, and the histological diagnosis of sclerosing mesenteritis was made. We treated the patient with corticosteroids and her symptoms and the radiographic findings improved. The coaxial technique was a useful and minimally invasive tool for making the diagnosis of sclerosing mesenteritis.

Sclerosing mesenteritis: a benign cause of mesenteric mass lesions.

Sclerosing mesenteritis is a rare disease of the mesentery. Associations with surgery, trauma, autoimmunity and paraneoplastic syndrome have been suggested, but most of the cases remain idiopathic. Diagnosis is often incidental, based upon the finding of a single or multiple mesenteric lesions on abdominal CT and histopathological confirmation. Optimal treatment is still controversial, but most of the cases reported have a favourable prognosis. We present a case of a 54-year-old male with long-standing abdominal pain and nausea, whose CT revealed the presence of a large mesenteric mass. A biopsy was performed, revealing benign chronic inflammation, fibrosis and IgG4-positive plasmocytes consistent with sclerosing mesenteritis. Clinical remission was achieved with corticosteroids and follow-up CTs at six and twelve months documented stability of the lesion. Furthermore, we review the current literature on the diagnosis and treatment options for this rare disease.

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.

Surgical management of isolated mesenteric autoimmune disease: addressing the spectrum of IgG4-related disease and sclerosing mesenteritis.

IgG4-related disease (IgG4-RD) is a rare form of autoimmune sclerosing disease, characterised by elevated serum IgG4 and tissue IgG4 levels, specific histopathological findings, multiorgan involvement and adequate response to glucocorticoid treatment. The low incidence and the heterogeneous nature of the disease has made consensus on diagnostic criteria for IgG4-RD difficult. Whether sclerosing mesenteritis (SM) is considered a manifestation of IgG4-RD is strongly debated. We present the case of a patient with a history of rheumatoid arthritis who presented with a calcified abdominal mass. She was found to have an isolated, pedunculated mesenteric mass positive for IgG4 and concurrently elevated serum IgG4 levels. Clinical features did not classify her disease as either SM or IgG4-RD as currently described in consensus statements. Concurrent diagnoses of IgG4-RD, SM and other autoimmune disorders, as well as postoperative recommendations for resected isolated IgG4-positive masses, are discussed.