A rare case report of immunoglobulin G4-related sclerosing mesenteritis and review of the literature

INTRODUCTION

Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a rare autoimmune disorder involving 1 or multiple organs, most commonly the pancreas, lacrimal glands, and salivary glands. However, IgG4-related sclerosing mesenteritis (SM) involving the small-bowel mesentery is rare. Given that IgG4-related SM usually mimics the imaging characteristics of mesenteric malignancies, its preoperative diagnosis remains challenging. In addition, no specific consensus has been reached regarding the treatment of IgG4-related SM. Therefore, a better understanding of the characteristics, treatment, and prognosis of IgG-related SM is urgently needed. Herein, we report a rare case of IgG-related SM.

PATIENT CONCERNS

A 67-year-old man was admitted to our hospital after incidental detection of an abdominal mass on ultrasound imaging, although he reported being generally well. The findings on triple-phase abdominal computed tomography were highly consistent with a malignant mesenteric tumor.

DIAGNOSES

The hallmark histopathological features along with elevated levels of IgG4 (145 mg/dL) and imaging findings were indicative of IgG-related SM.

INTERVENTIONS

The patient was treated surgically. Postoperative histopathological examinations exhibited tissue infiltration with lymphocytes and IgG4-positive plasma cells, as well as fibrosis.

OUTCOMES

Ten days after surgery, the patient was discharged from the hospital, and did not show any clinical sign of IgG-related SM within 1-year follow-up.

CONCLUSION

This case highlights the mesentery as an uncommon site of involvement as well as how early IgG-related SM can be completely asymptomatic. Thus, this study has advanced our knowledge of IgG-related SM and may improve treatments for similar conditions.

Sclerosing Mesenteritis Mimicking IgG4-related Disease

A 72-year-old man was followed as an outpatient at our hospital for 6 years after surgery for small cell carcinoma of left adrenal gland origin. Follow-up abdominal computed tomography showed a 6-cm mass in the left lower mesentery. The patient underwent open laparotomy. The histological diagnosis was sclerosing mesenteritis. The previous specimens of the left adrenal mass were then re-examined with a microscope, and panniculitis was found around the small cell carcinoma. Both lesions were histologically similar to IgG4-related disease (RD), but they did not completely meet the diagnostic criteria of IgG4-RD clinically or histologically.

Mesenteric panniculitis, a rare cause of acute surgical abdomen in children. Case report and literature review

Mesenteric panniculitis appears as a less known benign condition due to its infrequency and not fully elucidated etiology; currently, less than 20 cases in children have been reported. It is characterized by a fibrotic and inflammatory transformation of the mesentery fat of the small intestine and, less commonly, of the colon. The 8-year-old patient whose case we report presented in our Service complaining of acute digestive symptoms. A causality relation with the small yet frequent injuries the child suffered at the abdominal level during his sports practice may be hypothesized, although this correlation cannot be proven. Laboratory test values are usually within the normal range in such patients, yet the inflammatory values are sometimes high, just as in our case. The imagistic diagnostic workup detected a solid mass at the level of the hepatic colic flexure, with a non-homogenous structure, with fine contrast uptake in the walls; perilesional fatty infiltration with "misty mesentery" appearance; infracentimetric adenopathies located in the mesentery root. The tumor was surgically excised and intestinal anastomosis was performed. Achieving the final pathological diagnosis of mesenteric panniculitis was a difficult task, as it required several differential diagnoses, by ruling out a local vasculitis process and an idiopathic inflammatory Crohn's-like disease. The patient's post-operative evolution was positive. The follow-up examinations at one month, six months, one year and two years showed a good general condition, a good nutrition state and clinical-paraclinical test results within normal values. A significant association of mesenteric panniculitis to other malignancies, as well as a predisposition of these patients to the subsequent occurrence of neoplasms has been noted in adults. As these findings have not yet been proven in children, due to the small number of cases and the absence of prospective studies, long-term monitoring is an absolute must.

Extensive mesenteric lipodystrophy of the left colon: case report and brief review of the literature

Mesenteric lipodystrophy is a rare inflammatory process that predominantly affects mesenteric adipose tissue of the small bowell. Several mechanisms have been suggested as responsible for this entity although the precise etiolog remains unknown. The diagnosis is based on CT or MRI imaging and generally confirmed by surgical biopsies. Treatment is individualized and empiric and depends on disease stage and symptoms. We report a case of a 35-year-old male who was admitted to our hospital with a history of abdominal pain, constipation and a palpable mass in the left lower quadrant. Abdominal CT scan showed diffuse thickening of the descending and rectosigmoid colon, associated with increased density of the mesenteric fat. After failure ofan initial treat- ment with glucocorticoids, he underwent a laparoscopic sigmoidectomy. Histopatholog analysis revealed extensive stea- tonecrosis ofpericolonicfat and lipid-ladenfoamy cells which was consistent with the diagnosis of mesenteric lipodystrophy. Clinical presentation and treatment as well as a brief review of the literature are discussed.

Sclerosing mesenteritis: A case of acute abdomen and intestinal obstruction

Sclerosing mesenteritis (SM) is a rare idiopathic disorder characterized by chronic non-specific inflammation involving the adipose tissue of the bowel mesentery. It may be asymptomatic but it commonly presents with abdominal pain. Some individuals may have a palpable abdominal mass and affected individuals may develop small bowel obstruction or acute abdomen. We report a case of 27-year old man who presented to the Surgery Department at Chukwuemeka Odimegwu Ojukwu University Teaching Hospital (COOUTH), Amaku Awka, Anambra State with acute abdomen and intestinal obstruction. He subsequently, had a surgical resection, which was histologically confirmed as a sclerosing mesenteritis. Sclerosing mesenteritis is a rare disorder and this is the first case being reported in the literature from South-East, Nigeria.It is therefore, important to alert physicians, more especially the surgeons on the need to have a high index of suspicion in every case of intestinal obstruction.

Sclerosing Mesenteritis Presenting as a Pseudotumor of the Greater Omentum

OBJECTIVE

The aim was to demonstrate a diagnostic challenge of sclerosing mesenteritis initially considered as liposarcoma.

CLINICAL PRESENTATION AND INTERVENTION

A 45-year-old man was admitted with a painful abdominal mass. Abdominal computed tomography demonstrated a well- demarcated tumor in his left hemiabdomen, with a large fat component and areas of soft tissue attenuation suggestive of liposarcoma. Intraoperative findings showed a tumor arising from the greater omentum. The tumor was completely removed, and histopathology confirmed a pseudotumorous type of sclerosing mesenteritis with dominant mesenteric lipodystrophy.

CONCLUSION

This case showed that a pseudotumorous type of sclerosing mesenteritis should be considered in the differential diagnosis of the mesenteric tumors.

Uncommon solitary mesenteric mass: mesenteric panniculitis

Mesenteric panniculitis is a rare, benign disease characterized by a chronic non-specific inflammatory process of mesenteric fat tissue with unknown etiology. Its clinical outcome ranges from complete resolution without any treatment to rapid progression culminating in death. So far, there is no established treatment available for its management. A 53-year-old female was admitted to our hospital because of intermittent abdominal pain, abdominal distension and early satiety for three months. Her abdominal CT scan revealed a solitary, well-defined, heterogeneous mass with a diameter of approximately 3.5cm x 2.8cm in the mesentery of small bowel. Exploratory laparotomy revealed yellowish-grey mass with a gritty consistency and histopathology of the resected specimen confirmed it to be mesenteric panniculitis. An increased awareness may lead to the use of a less invasive diagnostic approach and optimal management of this rare disease entity.

[Successful endoscopic transpapillary pancreaticobiliary drainage for omental panniculitis by hepatocellular carcinoma complicated by biliary fistula and pancreatic fistula]

A 78-year-old man with hepatocellular carcinoma treated by chemoembolization and percutaneous ethanol injection was admitted to our hospital because of acute abdomen. The CT scan showed biliary fistula caused by hepatocellular carcinoma protruding from S3. Endoscopic retrograde cholangiopancreatography showed disruption of an intrahepatic duct and the main pancreatic duct, and contrast agent leaked into the peritoneal cavity from each duct. Omental panniculitis with biliary fistula and pancreatic fistula was diagnosed. The symptoms improved by endoscopic nasobiliary drainage and endoscopic pancreatic stenting. On the 13th day after admission, we added endoscopic nasopancreatic drainage because his abdominal pain had been exacerbated by pancreatic juice leakage. Omental panniculitis by hepatocellular carcinoma complicated by biliary fistula and pancreatic fistula is extremely rare. Endoscopic transpapillary pancreaticobiliary drainage was effective for omental panniculitis in this case.

Retractile mesenteritis appearing as a sigmoid colon tumor

Retractile mesenteritis is a rare, fibrosing, inflammatory disease affecting the adipose tissue of the intestinal and colonic mesentery. So far, about 300 cases have been reported in the literature. We present a case of retractile mesenteritis.

[Sclerosing mesenteritis. Presentation of three cases and review of the literature]

Sclerosing mesenteritis or panniculitis is a rare condition characterized by inflammation of the mesentery ranging from an acute to a chronic fibrotic process that can resemble an intestinal malignant neoplasm even though it is benign. Its etiology is unknown, although it is thought to be the result of a nonspecific inflammatory response of the mesentery to an allergic, chemical, thermal, infectious, autoimmune or surgical stimulus. Its natural history is benign and in most cases is self-limited. Surgery is reserved only for those cases where there is intestinal obstruction. We report three cases of sclerosing mesenteritis that occurred after abdominal surgery and we present a review of the literature.

MR findings in a rare case of sclerosing mesenteritis of the mesocolon

Sclerosing mesenteritis is a rare, usually benign disorder of the mesentery. Depending on the predominant tissue component (inflammation, fat, or fibrosis), it is known as mesenteric panniculitis or retractile mesenteritis. We present a rare case of retractile mesenteritis of the mesocolon as a cause of severe abdominal pain. US, CT, and MRI were the imaging modalities used. We emphasize the MR finding of a fibrous capsula in retractile mesenteritis, as this is to our knowledge the first study to describe this entity. This finding may be valuable for establishing a diagnosis of sclerosing mesenteritis, as well as for differentiating this disease from other mesenteric diseases.

[Minimally invasive technologies in diagnosis and treatment of local purulent complications of destructive pancreatitis]

Sixty patients with local purulent complications of destructive pancreatitis were treated. Interventional procedures under visual control were performed in 38 patients: in 26 (68.4%) -- under control of computed tomography and in 12 (31.6%) -- ultrasound-assisted procedures. Traditional surgeries were performed in 22 patients. Complete recovery was seen in 23 (60,6%) of 38 patients of the first group, all these patients have solitary, one-chamber and non-sequestered purulent cavities which are formed in 82.6% cases due to microfocal pancreonecrosis. Transcutaneous drainage was ineffective in 14 (36.8%) patients that required conversion to laparotomy. It is demonstrated that treatment policy in purulent-necrotic complication of pancreonecrosis must be individual. Adequate method of local treatment must be determined by size and localization of purulent and necrotic lesions, presence of sequesters and septa.

Sclerosing mesenteritis with occult ileal perforation: report of a case simulating extensive intra-abdominal malignancy

Sclerosing mesenteritis is a rare condition that is characterized by fibrosis affecting mainly small-bowel mesentery, which in extensive cases may mimic advanced intra-abdominal malignancy. Establishing the diagnosis in such cases is a clinical and histopathologic challenge. We report the successful management of a case of extensive sclerosing mesenteritis with occult ileal perforation, which was possibly the triggering cause. Severe complications occurred as a result of both the disease itself and its surgical treatment. Despite the complex course and life-threatening complications, a good prognosis can be expected. Although occasional recovery has been attributed to spontaneous regression and response to immunosuppressive therapy, a search for, and full eradication of, possible triggering focus is of paramount importance.

Sclerosing mesenteritis in small bowel transplantation: possible manifestation of acute vascular rejection

BACKGROUND

Acute rejection of human small bowel allografts is characterized by clinical symptoms combined with characteristic morphologic alterations. The typical geographic distribution of acute rejection in the bowel is involvement of the intestinal parenchyma, which can be transmural, particularly when the rejection is more severe. However, little is known concerning the potential for donor-derived soft tissue adjacent to the bowel to become involved by the host alloimmune response.

METHODS

We describe a male patient who, several weeks after combined small bowel and liver transplantation, demonstrated sclerosing mesenteritis with vasculitis and acute rejection of the bowel.

RESULTS

The vascular lesions in the mesentery demonstrated increased IgG deposition and the patient developed an alloantibody to the donor.

CONCLUSIONS

The changes described herein may represent a novel presentation of acute vascular rejection.

Mesenteritic panniculitis: detection by abdominal ultrasonography

OBJECTIVE

to describe the findings that allowed us to detect mesenteric panniculitis in sonographic abdominal studies.

PATIENTS AND METHODS

we retrospectively evaluated the images of 10 patients diagnosed of mesenteric panniculitis, initially detected by sonography. Diagnosis was confirmed by computed tomography (CT) in all cases, and by surgical biopsy in one of them. Two patients were symptomatic, and it was an incidental finding in the remaining eight cases.

RESULTS

the characteristic sonographic appearance consisted of thickening of mesenteric fat around mesenteric vessels, with an elliptical or rounded shape, a convex or lobulated and well-defined anterior border and an homogeneous or slightly heterogeneous structure, with nodular images in three of the cases. Mesenteric vessels were identified, without evidence of distortion. There was a reduction of compressibility in relation to normal mesenteric tissue.

CONCLUSION

although we cannot presently state the specificity of the findings described, mesenteric panniculitis can be detected by abdominal sonography. This technique provides guidance for the diagnosis and, eventually, percutaneous biopsy.

Concomitant sclerosing mesenteritis and bile duct fibrosis simulating Klatskin's tumor

Sclerosing mesenteritis is an uncommon benign condition that should be included in the differential diagnosis of abdominal masses. We present the first reported case of this condition in association with idiopathic bile duct fibrosis simulating Klatskin's tumor. A review of the literature regarding both clinical entities is presented.

Mesenteric panniculitis presenting as a huge retroperitoneal mass--a case report

A rare case of mesenteric panniculitis occurring in a young patient and presenting as a huge retroperitoneal mass which was mistaken for malignancy, has been described.

[Retractile mesenteritis after resection of Meckel's diverticulum]

HISTORY AND ADMISSION FINDINGS

A 22-year-old man who had never been seriously ill previously was admitted because of epigastric pain and vomiting of bile.

INVESTIGATIONS

He had slight pain on pressure over the epigatric region and decreased intestinal peristaltic sounds. There was evidence of ileus of the small intestine both by ultrasound and radiologically.

TREATMENT AND COURSE

As the patient's condition deteriorated on conservative treatment, an exploratory laparotomy was performed. It revealed an invaginated Meckel's diverticulum, Ileus of the small intestine recurred postoperatively, requiring relaparotomy. A glued-together volvulus of the small intestine had to be resected, even though there was no sign of an anastomotic leak. But there was no postoperative improvement. A third operation revealed a clearly shortened and 3 cm-thick mesentery which showed a stage III retractile mesenteritis. Histological re-examination of the specimens resected at the previous operations revealed stage I and II retractile mesenteritis. The patient's condition slowly improved on high doses of corticosteroids and he ultimately became symptom-free.

CONCLUSIONS

Retractile mesenteritis is a very rare benign disease of the mesentery, almost always causing abdominal pain and diagnosed histologically by exploratory laparotomy. Administration of corticosteroids is the treatment of choice.

Mesenteric panniculitis: case report and literature review

Mesenteric panniculitis is an extremely rare inflammatory condition of the adipose tissue of unknown etiology in which the mesentery is replaced with fibrosis. Knowledge of this rare syndrome should prevent any unwarranted aggressive therapy and help to use the clinical, radiological, and surgical sources to obtain the diagnosis. This paper is a review of symptomatology, pathology, treatment, and outcome of this disorder. A case report is described that presented with obstruction of the sigmoid colon.

"Medically necessary" panniculectomy to facilitate gynecologic cancer surgery in morbidly obese patients

A retrospective review of patients in our practice who underwent abdominal panniculectomy to facilitate gynecologic cancer surgery was performed. The objective of the study was to determine if panniculectomy was a safe and useful procedure in the morbidly obese gynecologic cancer patient. A total of 12 patients underwent the procedure between 1992 and 1996. Optimal pelvic oncologic surgery was accomplished in all 12 patients. All aspects of those procedures were performed by gynecologic oncologists. The Buchwalter retractor was used in all cases. The patients' weights ranged from 170 to 429 pounds, with a mean of 275 pounds. The mean body mass index was 48, with a range from 37 to 67. Four patients had a history of diabetes mellitus. Nine patients healed without wound complications. Three patients developed superficial subcutaneous wound infections/necrosis that were successfully managed with office debridement. Abdominal panniculectomy is a reasonably safe procedure that makes radical pelvic surgery possible regardless of the patient's weight. Prolonged wound bulb suction drainage may decrease the incidence of wound necrosis/infection in these high-risk patients.

[Mesenteric panniculitis]

We report three cases of mesenteric panniculitis in which the disease took different courses. The first case clinically mimicked an acute diverticulitis and consequently laparotomy was performed. During this operation a large space-occupying tumour was found in the lower abdomen. After resecting this tumour mass of uncertain classification (benign or malignant) a preternatural anus of sigmoid colon was formed. Histological exploration revealed mesenteric panniculitis. Six months later we restored continuity of large bowel by end-to-end anastomosis. No residues of the preexisting panniculitic alterations were seen. The second case concerned a female patient who again complained of discomfort after surgical treatment of colon carcinoma. We measured an elevated erythrocyte sedimentation rate and suspected a relapse of the malignant disease. Notwithstanding radiological and endoscopic diagnostics, the origin and classification of an intra-abdominal tumour could not be determined preoperatively. Laparoscopically we took a biopsy of the local mass, but a definite diagnosis was not found. Postoperatively undulant fever occurred, uninfluenced by cortisone treatment. Finally the patient died because of unstoppable hemorrhage under coagulopathy. Mesenteric panniculitis was identified as causative disease by autopsy.

[Panniculitis mesenterialis, a rare disease]

Panniculitis mesenterialis is an illness of the mesenterium of the small intestine and is not familiar to all clinical physicians. The rare reports in the literature mostly describe a good outcome with a few cases ending lethal. Pathologists paying attention to detect panniculitis during postmortem examination report about an incidence of about 1%. This discrepancy may be based on the fact that only extended changes of the mesenterial fat tissue cause symptoms. The pathological base consists in extensive necrosis of fat tissue with fibrosis of the mesenterium. Aetiology is unknown, diagnosis is usually made during laparotomy. There is no specific treatment, prognosis is generally good.

Mesenteric panniculitis presenting as a multilocular cystic mesenteric mass: CT and MR evaluation

Mesenteric panniculitis is a non-neoplastic, inflammatory process affecting the adipose tissue of the mesentery in adults with slight male predilection. Typical computed tomography (CT) or magnetic resonance imaging (MRI) findings are of either diffuse mesenteric infiltration or nodular mesenteric masses. We encountered a case of mesenteric panniculitis in a 26-year-old woman with the left upper quadrant pain and fullness, in which CT and MRI disclosed a large, ill-defined, multilocular cystic mesenteric mass. After surgery, the diagnosis of mesenteric panniculitis was made. The cystic components were dilated lymphatics due to lymphatic and venous obstruction by the mesenteric panniculitis.

[Mesenteric panniculitis of the sigmoid. A case report and review of the literature]

Mesenteric panniculitis is an extremely rare disease in which the normal fatty architecture of the mesentery is replaced by fibrosis, necrosis and calcification. One hundred twenty-four cases of mesenteric panniculitis have been described in the literature; only five of these involved the sigmoid mesentery. The following case report is of mesenteric panniculitis confined to the sigmoid colon. Symptomatology, pathology, treatment and outcome of this disorder are discussed. It seems that this disease is a well established clinical entity of unknown etiology with a benign course and favorable outcome. Radical surgical treatment is not advised. If mesenteric panniculitis is encountered at operation, biopsy to establish the diagnosis is indicated. If the mechanical effects are significant, they should be corrected.

Mesenteric panniculitis

We have reviewed the case of a young man with an omental mass diagnosed as mesenteric panniculitis. The clinical history, physical findings, and laboratory and radiologic studies were typical of this disorder. The diagnosis was suggested by CT scan, and confirmed on surgical biopsy. Our patient has had the typically benign course seen with mesenteric panniculitis.