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Mesenteric Panniculitis

David I Rose, MD
John M Braver, MD

August 23,1996

Presentation

A 76-year-old man presented with nausea, chronic abdominal pain, and weight loss.

Imaging Findings

Small bowel series
CT of abdomen

A small bowel series demonstrates mild-to-moderate dilatation of the small bowel with thickening of numerous valvulae conniventes (short arrows), yielding a spiculated pattern. The small bowel is fixed in a swirled pattern in the central abdomen, and focal areas of narrowing (long arrow) are visible. No obstruction is apparent.

Computed tomographic (CT) images enhanced with intravenous contrast show a somewhat well-defined soft tissue mass (black arrow) centered in the small bowel mesentery causing tethering of the bowel loops. High attenuation strands (arrows) emanate from the main soft tissue mass in the mesenteric fat. The mesenteric vessels (white arrow) are surrounded by this process, but they are not displaced. The small bowel is dilated.

Differential Diagnosis

Soft tissue attenuation in the mesenteric fat associated with tethering of the small bowel may represent a neoplastic process such as sarcoma or a carcinoid or desmoid tumor. However, tumors tend to displace vessels rather than surround them. Other diagnoses that must be considered include pancreatitis, inflammatory bowel disease, metastatic disease, and extra-abdominal fat necrosis (ie, Weber-Christian disease). Mesenteric lymphadenopathy, seen in such diseases as mesenteric adenitis, acquired immune deficiency syndrome, Whipple's disease, sprue, sarcoidosis, or tuberculosis, is a less likely consideration.

Diagnosis

Mesenteric panniculitis

Discussion

Mesenteric panniculitis is a nonspecific inflammatory and fibrotic process affecting the fatty tissue of the mesentery. The term retractile mesenteritis has been used to describe this process when the predominant component is fibrosis, and mesenteric lipodystrophy has been applied when the primary component is inflammation. Most cases are idiopathic. The age range of patients is wide with the peak incidence in the sixth and seventh decades. The male to female ratio is 1.8:1. Criteria for the diagnosis require exclusion of pancreatitis, inflammatory bowel disease, and extra-abdominal fat necrosis (Weber-Christian disease). Symptoms are variable and include abdominal pain, fever, nausea, vomiting, and weight loss. Symptoms often persist for a year or more. Physical examination may be unremarkable or may reveal abdominal tenderness or a palpable mass.

Radiologically, upper gastrointestinal and barium enema examinations may demonstrate displacement of bowel loops by a mesenteric mass with the jejunal mesentery most frequently involved. Bowel loops may be dilated, fixed or narrowed, but complete obstruction is rare. Fibrosis causes retraction of the mesentery. Bowel loop narrowing and spiculation mimic neoplastic disease or carcinoid tumor when the fibrotic component of this process predominates. Occasionally, ureteral obstruction is visible. CT provides the best means of imaging this lesion. On CT images, the appearance of the lesion can range from a well-defined soft tissue mass, often containing regions of fat, to ill-defined areas of higher attenuation in the mesenteric fat related to the inflammation and fibrosis. When the process is focal and fat attenuation is noted, it may mimic a teratomatous or liposarcomatous tumor. Although calcification is frequently noted on histologic examination, it is rarely seen radiographically.

Pathologically, loosely encapsulated firm or hard inflammatory masses of variable size are interspersed with nodules of fat and necrotic or liquefied fat. A variable amount of hemorrhage and fibrosis is present. Rarely, vascular thrombosis or extension of the inflammatory process into the retroperitoneum may occur.

References

Silverman PM, Cooper C. Mesenteric and omental lesions. In: Gore RM, Levine MS, Laufer I, eds. Textbook of gastrointestinal radiology. Philadelphia: Saunders, 1994: 2367-2374.

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