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Mesenteric panniculitis

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Mesenteric panniculitis BEN ROMDHANE MH Hopital AVICENNE BOBIGNY * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Mesenteric edema Many ... – PowerPoint PPT presentation

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Title: Mesenteric panniculitis


1
Mesenteric panniculitis
  • BEN ROMDHANE MH
  • Hopital AVICENNE BOBIGNY

2
Mesenteric panniculitis
  • inflammatory disorder of the fatty tissue of the
    bowel mesentery
  • Uncommon
  • several names( resulting in considerable
    confusion )
  • lipodystrophy,
  • mesenteric Weber-Christian disease,
  • fibrosing mesenteritis,
  • sclerosing mesenteritis
  • retractile mesenteritis

3
  • varied terminology reflects the pathological
    spectrum
  • now considered to be one single disease
  • chronic nonspecific inflammatory process in the
    mesentery
  • rarely may lead to fibrosis and retraction
  • If inflammation predominates over fibrosis
  • the process is known as mesenteric
    panniculitis
  • when fibrosis and retraction predominate, terms
    fibrosing mesenteritis, retractile mesenteritis
    or sclerosing mesenteritis are more commonly used

4
  • MP supposed to be very rare, approximately 250
    cases reported in the literature
  • With increased use of abdominal diagnostic
    imaging, MP is diagnosed more often
  • Recently reported prevalence of 0.6 of all
    patients undergoing an abdominal CT for various
    indications

5
Pathogenesis
  • infiltration of mesenteric fat by
  • inflammatory cells, mainly lymphocytes
  • and fat-laden macrophages
  • with inflammation, a mixture of fat necrosis and
    fibrosis may be present in the mesentery
  • exact cause remains unclear

6
  • MP occurs independently or in association with
    other disorders
  • A variety of possible causative factors have been
    proposed
  • autoimmune disorders
  • ischemia
  • prior abdominal surgery

7
  • also suggested paraneoplastic response
  • This possible association with a concomitant
    malignancy highlighted in a study by
    Daskalogiannaki
  • reporting the presence of a coexisting abdominal
    or distal malignancy in 69 of patients with CT
    features of MP
  • In other studies prevalence of malignancy not
    different from general population of patients
    undergoing CT for all various indications

8
Clinical characteristics
  • mostly middle or late adulthood,
  • male predominance.
  • Clinical manifestations may be related to the
    inflammation or to mass-effect
  • Presenting symptoms may vary
  • may also be entirely asymptomatic
  • commonly include non-specific abdominal pain
  • Palpable abdominal mass may be present may lead
    to the clinical misdiagnosis (aortic aneurysm
    ...)

9
  • Laboratory findings often within the normal
    range or demonstrate non-specific findings
  • mild leucocytosis and elevation of the
    erythocyte sedimentation rate.
  • before the advent of modern diagnostic imaging,
    MP was diagnosed exclusively as an unexpected
    finding at exploratory laparotomy or autopsy

10
Diagnosis
  • A definite diagnosis of MP can be made only by
    pathologic analysis
  • However, the incidental benign and often
    asymptomatic nature of MP usually does not
    justify biopsy
  • In these cases, diagnosis may be suggested by
    characteristic imaging features from the
    radiological literature from pathologically
    proven cases

11
US features
  • often quite subtle may be easily overlooked
  • poorly defined hyperechoic change of the
    mesenteric fat
  • decrease in mesenteric compressibility
  • may be seen in various conditions with
    mesenteric involvement( lipomatous tumors...
  • CT always recommended to analyze any US-found
    mesenteric abnormalities

12
  • A. C. van Breda Vriesman Eur Radiol (2004)

13
CT features
  • increased density of mesenteric fatty tissue
    (approximately- 40 to -60 HU) compared to the
    attenuation values of normal retroperitoneal or
    subcutaneous fat
  • (-100 to -160 HU)
  • hyperattenuating fat surrounds mesenteric vessels
  • but does not displace them
  • some regional mass-effect by displacing locally
    small bowel loops
  • mass most frequently located at the left side
  • corresponding to jejunal mesentery

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  • Piessen G Annales de chirurgie 131 2006

17
  • Other CT features reported
  • may be valuable clues for the diagnosis
  • the fat-ring sign,
  • tumoral pseudocapsule
  • soft-tissue nodules

18
Fat-ring sign
  • Fat-ring sign or fatty halo 7585
  • low-density fat surrounding vessels and nodules
  • preservation of normal fat density, corresponding
    to unaffected noninflamed fat interposed between
    vessels or nodules and inflammatory cells at
    histopathology
  • non-specific
  • also reported incidentally in non-Hodgkins
    lymphoma in which chemotherapy treatment has led
    to reduction of the mesenteric lymphadenopathy,
    leaving a fine haziness throughout the mesenteric
    fat

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20
Tumoral pseudocapsule
  • peripheral band with soft-tissue attenuation
    limiting the inflammatory mesenteric mass
  • thickness of this dense stripe usually does not
    exceed 3 mm
  • reported in 5059 of patients
  • lipomatous tumor (lipoma or liposarcoma) may be
    well-defined by a similar dense rim
  • but these lesions will often show some
    mass-effect on the mesenteric vessels in contrast
    to M P

21
  • A. C. van Breda Vriesman Eur Radiol (2004)

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Soft-tissue nodules
  • small soft-tissue nodules scattered within the
    hyperattenuating mesenteric mass
  • in 80 of cases
  • Correspond probably to lymph nodes
  • usually less than 5 mm in diameter
  • Mesenteric lymph nodes larger than 10 mm atypical
    for MP
  • biopsy or fine-needle aspiration must be
    considered to exclude malignancy

24
SM
  • most commonly appears as a soft-tissue mass in
    the small bowel mesentery
  • The mass may envelop the mesenteric vessels, and
    collateral vessels
  • Mesenteric thickening and fibrosis
  • often with nodular masses involving the
    appendices epiploicae of the colon

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  • Calcification may be present, usually in the
  • central necrotic portion of the mass
  • it may be related to the fat necrosis
  • Cystic components also described
  • may be the result of lymphatic or venous
    obstruction and necrotic change
  • Enlarged mesenteric or retroperitoneal lymph
    nodes may be present

28
  • Farzana Nawaz Ali, Case Reports in Medicine2010

29
  • Farzana Nawaz Ali, Case Reports in Medicine 2010

30
Imaging-based differential diagnosis
  • misty mesentery Alteration in the density of the
    mesenteric fat on CT
  • with an extensive differential diagnosis
  • MP reserved for idiopathic inflammation leading
    to a misty mesentery

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33
  • imaging diagnosis can therefore be made only
    after exclusion of any of the following
    alternative causes of a misty mesentery

34
Mesenteric edema
  • Many causes
  • heart failure, portal hypertension, mesenteric
    vascular thrombosis and lymphedema.
  • mesenteric edema secondary to a systemic disease,
    usually associated with generalized subcutaneous
    edema and ascites.
  • Ascites is not a feature of MP and indicates an
    alternative diagnosis

35
Inflammation
  • acute pancreatitis is the typical inflammatory
    process associated with increased CT density of
    the mesenteric fat
  • usually centered in the peripancreatic region
  • With usually increased levels of amylase in
    serum and urine enabling the diagnosis
  • Focal inflammations such as appendicitis and
    colonic diverticulitis may also cause local
    hyperattenuation of adjacent mesenteric fat
  • these diagnoses must be carefully ruled out

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37
Mesenteric Hemorrhage
  • hemorrhage, caused by blood dissecting from
    mesenteric vessels or from the bowel wall
  • may be traumatic or spontaneous
  • A history of trauma, use of anticoagulantia
  • or high-density peritoneal fluid suggests the
    correct diagnosis

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Neoplasm
  • Non-Hodgkins lymphoma most common mesentery
    tumor
  • Typically bulky lymphadenopathy,
  • often also n the retroperitoneum, indicating the
    correct diagnosis
  • Shrinkage of mesenteric lymphadenopathy after
    chemotherapy may result in residual scarring that
    may mimic MP
  • Needs reviewing the patients prior CT scans

40
  • lymphoma manifested as nodal mass in the root of
    the mesentery may mimic SM
  • no calcification unless previously treated
  • Both can encase mesenteric vasculature
  • lymphoma almost never result in ischemia
  • fat halo sign favors a diagnosis of SM
  • large, nodes favor lymphoma
  • Treated lymphoma may also produce a misty
    mesentery simulating the MP

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44
  • Primary mesenteric neoplasms (desmoid, mesenteric
    cyst, lipomatous tumors) cause mass-effect on
    mesenteric vessels
  • Other tumors mesothelioma, or metastatic
    tumors( pancreatic, colon or ovarian carcinoma
    ) may affect the mesentery by soft-tissue tumor
    deposits, or may cause mesenteric edema by
    lymphatic obstruction
  • correct diagnosis made by identification of the
    primary tumor or detection of extra-mesenteric
    peritoneal nodules, or by cytological analysis of
    ascites

45
  • A. C. van Breda Vriesman Eur Radiol (2004)

46
  • Carcinoid tumor may simulate SM
  • ill-defined, infiltrating soft-tissue mass in
    the root of the mesentery with calcification and
    desmoplastic reaction
  • fat ring sign favors a diagnosis of SM
  • enhancing mass in bowel wall or hypervascular
    liver metastases
  • sign diagnosis of carcinoid tumor

47
  • primary mesenteric mesothelioma can produce
    mesenteric soft-tissue implants
  • in mesentery, also seen in the omentum and
    along the bowel surfaces.
  • Ascites not associated with SM
  • Calcification not common

48
Treatment
  • Treatment usually empirical
  • may consist of steroids, colchicine,
    immunosuppressive agents, or orally administered
    progesterone
  • In SM Surgical resection difficult
  • due to vessel compromise
  • may be of no clear benefit
  • colostomy may be necessary
  • with colonic involvement by SM

49
  • Variable course With treatment
  • relatively benign course
  • progression of the disease
  • eventually leads to death
  • In some cases, complete resorption

50
  • CT suggest the diagnosis of SM
  • CT useful in distinguishing SM from other
    mesenteric diseases such as lymphoma or carcinoid
    tumor
  • Biopsy necessary for SM diagnosis
  • CT optimal study for the follow up
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