An Uncommon Cause of Abdominal Pain in the Elderly: A Case Report of Mesenteric Panniculitis

Abstract

Mesenteric panniculitis is an uncommon idiopathic inflammatory condition affecting the adipose tissue of the mesentery, characterized by nonspecific manifestations, which present challenges in its diagnosis. We herein document the case of a 75-year-old female patient whose manifestations include diffuse abdominal pain over a period of four days. The diffuse abdominal pain was accompanied by nausea and decreased food intake on presentation. The patient was not experiencing fever, vomiting, or bowel/bladder symptoms. The abdomen was soft with periumbilical and epigastric tenderness, while bowel sounds were normal. There were no signs of organomegaly. Routine investigations were mostly within normal limits, with slight signs of inflammation. Ultrasonography findings were inconclusive. In the case of contrast-enhanced computed tomography (CECT) of the abdomen, the findings showed increased attenuation and signs of inflammation in the mesenteric fat, indicating mesenteric panniculitis, and no signs of obstruction or mass lesions. The patient was conservatively treated with analgesics, proton pump inhibitors, and antibiotics. The condition of the patient improved significantly. The patient recovered, and her condition was stable. She was advised to return for a follow-up. Early radiological detection is important for the avoidance of surgical intervention, thereby producing a positive outcome..

Keywords

Introduction

Mesenteric panniculitis (MP) is a rare, chronic inflammatory disorder of the mesenteric adipose tissue and is considered part of the spectrum of sclerosing mesenteritis, which ranges histologically from mesenteric lipodystrophy to fibrosis ^1,2. The exact etiology remains unclear; however, it has been associated with prior abdominal surgery, trauma, infection, autoimmune conditions, ischemia, drug exposure, and malignancy ^1,2. MP most commonly affects individuals in the fifth to sixth decades of life and demonstrates a slight male predominance ¹. The reported prevalence on abdominopelvic computed tomography (CT) is approximately 0.6% ². Clinically, patients may be asymptomatic or present with nonspecific symptoms such as abdominal pain, nausea, vomiting, bloating, fever, weight loss, or occasionally features of intestinal obstruction ¹. Laboratory findings are generally nonspecific, although inflammatory markers such as leukocytosis and elevated C-reactive protein may be observed ¹. Contrast-enhanced CT plays a central role in diagnosis. Characteristic radiological features include increased attenuation of mesenteric fat (“misty mesentery”), a well-defined mass effect, small soft tissue nodules, the fat halo sign, and the presence of a pseudocapsule ^1,2. Although histopathological examination remains the gold standard for definitive diagnosis, many cases are diagnosed based on typical imaging findings ¹. MP is generally considered a benign and often self-limiting condition, but standardized diagnostic criteria and treatment guidelines are lacking ¹.

MATERIALS & METHODS

Study Design: Single-patient case report

Diagnostic Tool Used: USG abdomen and pelvis, CECT of abdomen and pelvis

Data Sources: Clinical presentation, physical examination, imaging findings

Ethical Considerations: Patient identity not disclosed

CASE PRESENTATION

A 75-year-old female patient presented with generalized abdominal pain for the past four days. Nausea and decreased oral intake were other symptoms experienced by this patient. However, there was no history of fever, vomiting, constipation, diarrhea, or urinary symptoms. Also, there was no significant history of surgeries and traumatic injuries. The patient was hemodynamically stable. With respect to the abdominal region, although the abdomen was soft, there was tenderness in the periumbilical and epigastric region. However, there was no guarding, rigidity, and organomegaly. Even the bowel sounds were present and normal. Routine investigation results were within normal limits with mild inflammatory signs. Ultrasonography of the abdomen and pelvis was attempted; this was inconclusive, showing no definite signs of bowel obstruction, mass lesion, and intra-abdominal pathology. Contrast-Enhanced Computed tomography Further evaluation of the findings with contrast-enhanced computed tomography of the abdomen and pelvis showed that there was an increase in attenuation and stranding of the mesenteric fat in the periumbilical and left lumbar regions with associated inflammatory changes. Associated findings of small mesenteric lymph nodes were observed. There were no findings indicative of any bowel obstruction. The findings observed suggested the presence of mesenteric panniculitis.

DISCUSSION

Mesenteric panniculitis (MP) is a rare, chronic inflammatory disorder of the mesenteric adipose tissue characterized by varying degrees of fat necrosis, chronic inflammation, and fibrosis. It is considered part of the spectrum of sclerosing mesenteritis and is often detected incidentally on abdominal imaging performed for unrelated indications. The reported prevalence on computed tomography ranges from 0.16% to 3.4%, with a higher incidence in older adults and a slight male predominance.^3,4 The etiology remains unclear; however, proposed mechanisms include prior abdominal surgery, trauma, autoimmune processes, ischemia, infection, and association with malignancy.^5,6 Some studies have demonstrated a possible association between mesenteric panniculitis and underlying neoplasms, particularly lymphomas and gastrointestinal malignancies, although a direct causal relationship has not been conclusively established.⁶ Clinically, patients may present with nonspecific symptoms such as abdominal pain, nausea, vomiting, weight loss, or altered bowel habits, while some remain asymptomatic.³ In our case, the patient presented with diffuse abdominal pain and nausea without obstructive features. Radiologically, characteristic findings include increased attenuation of mesenteric fat (“misty mesentery”), small clustered lymph nodes, a pseudocapsule, and the “fat ring sign,” which are considered relatively specific for MP.^4,7 Cross-sectional imaging plays a crucial role in diagnosis and helps differentiate MP from other causes of mesenteric inflammation or malignancy. Management is primarily conservative in asymptomatic or mildly symptomatic cases. Treatment options for symptomatic patients include corticosteroids, colchicine, tamoxifen, or immunosuppressive agents. Surgical intervention is rarely required and is reserved for complications such as bowel obstruction.^5,7 The overall prognosis is favorable, and many cases show spontaneous resolution or remain stable on follow-up imaging.

RESULT

A rare inflammatory disease of the mesenteric adipose tissue, mesenteric panniculitis frequently shows as general abdominal symptoms, especially in older patients. It can be difficult to diagnose because of its irregular clinical presentation, which can resemble other intra-abdominal pathologies. In order to make the diagnosis and avoid unnecessary surgery, cross-sectional imaging is essential. The majority of cases have favorable outcomes and respond well to conservative management. For the better patient outcomes, early detection and suitable radiological evaluation are important.

REFERENCES

1. Zhao ME, Zhang LQ, Ren L, Li ZW, Xu XL, Wang HJ, et al. A case report of mesenteric panniculitis. J Int Med Res. 2019;47(7):3354–3359.
2. Newman PA, Thahal H, Chaudhery B. Mesenteric panniculitis. BMJ Case Rep. 2014;2014:bcr2014203911.
3. Emory TS, Monihan JM, Carr NJ, Sobin LH. Sclerosing mesenteritis: clinical, pathologic, and radiologic features. Am J Surg Pathol. 1997;21(4):392–398.
4. Daskalogiannaki M, Voloudaki A, Prassopoulos P, et al. CT evaluation of mesenteric panniculitis: prevalence and associated diseases. AJR Am J Roentgenol. 2000;174(2):427–431.
5. Issa I, Baydoun H. Mesenteric panniculitis: various presentations and treatment regimens. World J Gastroenterol. 2009;15(30):3827–3830.
6. van Putte-Katier N, van Bommel EFH, Elgersma OE, Hendriksz TR. Mesenteric panniculitis: prevalence, clinicoradiological presentation and 5-year follow-up. Br J Radiol. 2014;87(1037):20140451.
7. Coulier B. Mesenteric panniculitis: part of the spectrum of sclerosing mesenteritis—imaging findings. JBR-BTR. 2011;94(5):229–240.