Project Title

Mesenteric panniculitis, an unusual presentation of abdominal pain

Authors' Affiliations

Ankit Patel, Quillen College of Medicine, East Tennessee State University, Johnson City, TN. Yazan Alkawaleet, Division of Internal medicine, Quillen College of Medicine, East Tennessee State University, Johnson City, TN. Mark Young, Division of Hepatology and Gastroenterology, Quillen College of Medicine, East Tennessee State University, Johnson City, TN. Chakradhar Reddy, Division of Hepatology and Gastroenterology, Quillen College of Medicine, East Tennessee State University, Johnson City, TN.

Location

Mt Mitchell

Start Date

4-12-2019 9:00 AM

End Date

4-12-2019 2:30 PM

Poster Number

128

Faculty Sponsor’s Department

Health Sciences

Name of Project's Faculty Sponsor

Dr. Heather Grove

Type

Poster: Competitive

Classification of First Author

Medical Student

Project's Category

Digestive System

Abstract Text

Introduction:

Sclerosing mesenteritis is a rare autoimmune disease that eventually evolves into fibrotic changes affecting the adipose tissue around the mesenteric vessels. It can present through a myriad of gastroenterological as well as constitutional symptoms including but not limited to abdominal pain, diarrhea, fever, nausea or vomiting. Although the exact etiology of the disease is yet to be determined, there are several predisposing factors the most common of which is history of previous abdominal trauma and/or surgery. This is a case report of abdominal mesenteric panniculitis that presented with abdominal pain in a middle-aged male with history of cholecystectomy.

Case Presentation:

The patient was a 53-year-old male with past medical history of hypertension who presented with a 2-week history of intolerance to food and liquids and abdominal pain, colicky in nature, radiating to both flanks with no alleviating or relieving factors. One year before, the patient had cholecystectomy due to biliary dyskinesia. His hospital stay at that time was complicated by biliary leak treated with biliary stenting. He later also developed multiloculated abscess collection in the gallbladder fossa that was managed with external drainage and IV antibiotics. In the ER his vital signs were as the following: BP between 120-130/70-80, HR 70s, temperature 97, oxygen saturation was more than 95%. On physical examination, he had abdominal tenderness in all four quadrants with no rigidity, rebound tenderness, masses or skin changes. CBC showed WBC of 7K with no shift to the left, hemoglobin of 15.6 and platelets of 107. CMP showed Na of 142, K 4.2, Chl 19, Glu 99, Ca 9.5, AG 18, lactic acid 1, lipase 50, phos 2.7, beta-hydroxybutyrate 0.12 and Mg of 1.9. urine analysis and Troponins were within normal limits. EKG showed sinus rhythm. Urine drug screen was negative. CRP and ESR were within normal limits. Porphyria workup was negative. Alpha-1-antitrypsin was 123. Ceroluplasmin level was 17. Actin antibody was negative as well as mitochondria M2 antibody. CT angiogram of the abdomen showed patent mesenteric vessels. However, fat stranding was noticed especially at the root of the mesenteric vessels. The patient was placed on prednisone 40mg once daily and tamoxifen. His abdominal pain greatly improved after 2 days. He was discharged with a prolonged prednisone taper. He was scheduled for an appointment with his primary care at discharge but didn’t show up and was lost to follow up.

Conclusion:

Mesenteric panniculitis is a rare cause of abdominal pain. it is divided based on histological features into sclerosing (retractile) mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy. Diagnoses is usually rarely inferred from the clinical presentation and is often suggested by radiological features. Distinctive findings on CT include fat ring sign and pseudotumor capsule. Although radiological characteristics are helpful, histological proof is essential for definitive diagnosis, especially with an atypical clinical and radiological appearance. There is no consensus on the optimal treatment option but prolonged steroid taper has been used with various degrees of success.

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Apr 12th, 9:00 AM Apr 12th, 2:30 PM

Mesenteric panniculitis, an unusual presentation of abdominal pain

Mt Mitchell

Introduction:

Sclerosing mesenteritis is a rare autoimmune disease that eventually evolves into fibrotic changes affecting the adipose tissue around the mesenteric vessels. It can present through a myriad of gastroenterological as well as constitutional symptoms including but not limited to abdominal pain, diarrhea, fever, nausea or vomiting. Although the exact etiology of the disease is yet to be determined, there are several predisposing factors the most common of which is history of previous abdominal trauma and/or surgery. This is a case report of abdominal mesenteric panniculitis that presented with abdominal pain in a middle-aged male with history of cholecystectomy.

Case Presentation:

The patient was a 53-year-old male with past medical history of hypertension who presented with a 2-week history of intolerance to food and liquids and abdominal pain, colicky in nature, radiating to both flanks with no alleviating or relieving factors. One year before, the patient had cholecystectomy due to biliary dyskinesia. His hospital stay at that time was complicated by biliary leak treated with biliary stenting. He later also developed multiloculated abscess collection in the gallbladder fossa that was managed with external drainage and IV antibiotics. In the ER his vital signs were as the following: BP between 120-130/70-80, HR 70s, temperature 97, oxygen saturation was more than 95%. On physical examination, he had abdominal tenderness in all four quadrants with no rigidity, rebound tenderness, masses or skin changes. CBC showed WBC of 7K with no shift to the left, hemoglobin of 15.6 and platelets of 107. CMP showed Na of 142, K 4.2, Chl 19, Glu 99, Ca 9.5, AG 18, lactic acid 1, lipase 50, phos 2.7, beta-hydroxybutyrate 0.12 and Mg of 1.9. urine analysis and Troponins were within normal limits. EKG showed sinus rhythm. Urine drug screen was negative. CRP and ESR were within normal limits. Porphyria workup was negative. Alpha-1-antitrypsin was 123. Ceroluplasmin level was 17. Actin antibody was negative as well as mitochondria M2 antibody. CT angiogram of the abdomen showed patent mesenteric vessels. However, fat stranding was noticed especially at the root of the mesenteric vessels. The patient was placed on prednisone 40mg once daily and tamoxifen. His abdominal pain greatly improved after 2 days. He was discharged with a prolonged prednisone taper. He was scheduled for an appointment with his primary care at discharge but didn’t show up and was lost to follow up.

Conclusion:

Mesenteric panniculitis is a rare cause of abdominal pain. it is divided based on histological features into sclerosing (retractile) mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy. Diagnoses is usually rarely inferred from the clinical presentation and is often suggested by radiological features. Distinctive findings on CT include fat ring sign and pseudotumor capsule. Although radiological characteristics are helpful, histological proof is essential for definitive diagnosis, especially with an atypical clinical and radiological appearance. There is no consensus on the optimal treatment option but prolonged steroid taper has been used with various degrees of success.