Case Presentation: A 56 year-old woman with past medical history of gastritis and past surgical history of appendectomy and C-section presented with a six-month history of intermittent abdominal discomfort, non-bloody diarrhea, nausea and bloating that was significantly worsening during the week prior to admission. In a span of six months, the patient was noted to have a 45-pound weight loss. An outpatient workup prior to admission was significant for a normal transvaginal ultrasound and a colonoscopy significant only for benign polyps. However, given persistent symptoms in the setting of a consistently negative workup, she presented to the ER for further evaluation.
On examination, her abdomen was distended with positive bowel sounds. Pain was noted on deep palpation in all four quadrants. A CT scan of the abdomen and pelvis indicated mild haziness of the small bowel mesentery, possibly due to mesenteric panniculitis. She was referred to gastroenterology and started on a trial of steroids. She underwent a repeat CT scan after completing a 4-week course of prednisone indicated no improvement in haziness around the small bowel mesentery. The patient was then referred to rheumatology to rule out autoimmune conditions and labs were significant for an elevated CRP of 8.04 and a normal ESR. A second line agent, tamoxifen, was initiated in conjunction with prednisone and that patient had notable improvement in symptoms.

Discussion: The above case presents a unique cause of persistent abdominal pain secondary to mesenteric panniculitis, which is a nonspecific inflammation of mesentery surrounding the small bowel. The incidence is less than 1% with a male predominance(2:1), and the etiology is rooted in autoimmune dysfunction. Biopsied lesions indicate chronic fibrous changes. Mesenteric panniculitis can be associated with trauma, malignancy or vascular disease. Often times, this condition is limited to radiographic findings, but when symptomatic, patients are noted to have weight loss, abdominal pain, and elevated inflammatory markers.

A new study states that 28% of CT findings of mesenteric panniculitis are associated with malignancies such as lymphoma, colon cancer or renal cancer. The malignancy and autoimmune work up for our patient has been negative, and her surgical history is the likely explanation for her development of this condition. Clinical progression of mesenteric panniculitis ranges from weeks to decades. Most cases resolve spontaneously, but in symptomatic patients, treatment options include steroids, other anti-inflammatory agents such as colchicine and azathioprine along with tamoxifen, as single or combination therapies. Removal of mesenteric mass for symptom improvement is not recommended.

Conclusions: Diagnosis of mesenteric panniculitis is based on radiographic findings and does not require treatment unless the patient is symptomatic. Most patients respond well to a course of steroids given that the pathophysiology of the condition is rooted in chronic fibrous inflammation of the mesentery. If the condition is refractory to steroids, tamoxifen may be considered as adjunctive therapy.