American Journal of Emergency Medicine 33 (2015) 1328.e1–1328.e2
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
An unusual cause of acute abdominal pain: mesenteric panniculitis Mesenteric panniculitis is among the rare causes of abdominal pain, and its diagnosis is difficult for not only physicians but also radiologists. We aimed to present clinical and radiological findings of 2 patients admitted to the emergency department because of abdominal pain and diagnosed with mesenteric panniculitis, and discuss the relevant current literature. Emergency physicians who treat many patients with abdominal pain should remember mesenteric panniculitis when making differential diagnosis especially in patients with pain localized to left paraumbilical region. It should be known that computed tomography is highly useful in establishing the diagnosis. It is also important to remember that symptoms of most of those patients decline spontaneously and that conservative follow-up alone is sufficient for those cases, but surgical treatment may be the first choice in cases with progressively worsening symptoms. Abdominal pain is an important symptom accounting for 5% to 10% of emergency department (ED) admissions [1]. Hospitalization is required in 20% to 25% of cases, whereas 35% to 40% take the diagnosis of nonspecific abdominal pain because their diagnostic test results are all found to be normal and pain subsides on its own [2]. That high ratio of cases taking the diagnosis of nonspecific abdominal pain makes it mandatory for emergency physicians to be more careful. It will be helpful to know all possible causes of abdominal pain in starting specific treatment by reducing the number of patients taking the diagnosis of nonspecific abdominal pain. Mesenteric panniculitis (MP) is among the rare causes of abdominal pain, and its diagnosis is difficult for not only physicians but also radiologists. We aimed to present clinical and radiological findings of 2 patients admitted to ED because of abdominal pain and diagnosed with MP, and discuss the relevant current literature. A 36-year-old male patient was admitted to the ED because of abdominal pain. It was learned that his pain had started approximately 12 hours ago and that it was more prominent on his left side. There were no significant features in his medical history and in results of laboratory tests. Some tenderness and minimal guarding were present around the umbilicus. Computed tomographic (CT) scan showed a heterogenic mass lesion approximately 13 × 7 cm in dimension, at a density of − 77 HU with a well-defined hyperdense thin sheath, encircling superior mesenteric artery and superior mesenteric vein and causing minimal displacement of nearby intestinal segments (Fig. 1). The patient was diagnosed with MP and was taken to clinical and radiologic follow-up. A 59-year-old female patient was admitted to the ED because of complaints of abdominal pain and mild fever. It was learned that her pain had started approximately 5 hours ago and that it was more prominent on her left side. She had a history of hypertension. She was suffering from constipation periodically. Some tenderness was present
0735-6757/© 2015 Elsevier Inc. All rights reserved.
over the whole abdomen, and guarding was present in the left lower quadrant. Her blood pressure was 150/80 mm Hg, pulse rate was 74 beats per minute, and body temperature was 37.4°C. Results of her laboratory tests were normal. Abdominal ultrasound (USG) showed a minimally hyperechoic lesion with a normal vasculature in the mesentery on the left side. Computed tomography showed a heterogenic mass lesion approximately 9 × 5 cm in dimension, at a density of − 40 HU with a well-defined hyperdense thin sheath, encircling vascular structures and causing minimal displacement of nearby intestinal segments (Fig. 2). The patient was diagnosed with MP and was taken to clinical follow-up. It was seen on CT that her lesion became smaller on the 20th day when her symptoms also subsided. Mesenteric panniculitis is a rare disease characterized by a chronic nonspecific inflammation of mesenteric adipose tissue. Its exact cause is not known. It is suggested that causative factor may be infections, trauma, ischemia, malignancy, or vasculitis. It commonly affects small intestinal mesentery; but less commonly, colonic mesentery may also be affected. It generally originates from the root of mesentery at central plane and proceeds to the left of midline [3]. It is often seen between the ages of 50 and 60 years. It is 2 times more common in men [4]. Various symptoms may be seen in MP. The most commonly seen symptoms are abdominal pain, which is generally seen in the central region or on the upper quadrants, and an abdominal mass. Additionally, abdominal distention; loss of appetite; fever; nausea; vomiting; weight loss; diarrhea; constipation; and, less commonly, ascites and pleural or pericardial effusion may be seen. Symptoms may be progressive or periodic as well as self-limiting and subsiding in a short time [5]. Results of laboratory tests are commonly normal and do not help establish the diagnosis. Conventional abdominal radiographs and barium radiographs do not give any diagnostic information. Abdominal USG and CT are important studies to establish the diagnosis [4]. Diagnosis is commonly established by detection of CT criteria, although there are some cases diagnosed with USG in the literature; thus, CT alone is sufficient for the diagnosis [3,6,7]. Characteristic findings of MP on CT include adipose mass with well-defined borders, encircling superior mesenteric vessels, displacement of nearby bowel segments without any invasion, and nodular soft tissue lesions smaller than 5 mm in diameter [3]. There are some cases in whom surgical treatment was applied in the literature, whereas it was seen that symptoms of those patients did not decline but even worsened progressively. In a study, including 49 cases, performed by Daskalogiannaki et al [3], surgical treatment was applied to symptomatic cases only; and the other ones were followed up with periodic CT examinations. Corticosteroids and cyclophosphamide are suggested to be used in medical treatment of MP; however, some studies noting that it is a self-limiting disease and its symptoms decline spontaneously are also present [4]. Spontaneous remission of symptoms and improvement in CT findings were seen in our female patient; but
1328.e2
A. Buyukkaya et al. / American Journal of Emergency Medicine 33 (2015) 1328.e1–1328.e2
Fig. 1. A heterogenic mass lesion with a hyperdense thin sheath (arrow head), originating from mesenteric adipose tissue and encircling superior mesenteric artery (dashed arrow) and superior mesenteric vein (v), and accompanying normal lymph nodes (white arrow) are seen on axial (A) and sagittal (B) CT scans of our 36-year-old patient. Density difference between normal mesenteric adipose tissue and heterogenic inflamed mesenteric tissue is seen.
Fig. 2. Thin hyperdense sheath (arrow head) and vascular structures within the mass lesion are apparent on axial CT of our 59-year-old female patient.
our male patient was not as lucky as her, and his symptoms and radiological findings did not regress. In conclusion, emergency physicians who treat many patients with abdominal pain should remember MP when making differential diagnosis especially in patients with pain localized to left paraumbilical region. It should be known that CT is highly useful in establishing the diagnosis. It is also important to remember that symptoms of most of those patients decline spontaneously and conservative follow-up alone is sufficient for those cases, but surgical treatment may be the first choice in cases with progressively worsening symptoms.
Mehmet Ali Ozel Ramazan Buyukkaya Duzce University, School of Medicine, Department of Radiology Ayhan Sarıtas Duzce University, School of Medicine, Department of Emergency Medicine
http://dx.doi.org/10.1016/j.ajem.2015.02.050 References
Ayla Buyukkaya, MD Duzce Ataturk Government Hospital, Department of Radiology Corresponding author. Department of Radiology, Duzce Ataturk Goverment Hospital, Duzce, Turkey Tel.: +90 380 5292300 E-mail address: [email protected] Harun Gunes, MD Duzce University, School of Medicine, Department of Emergency Medicine Ismet Ozaydın Duzce University, School of Medicine, Department of General Surgery
[1] Esses D, Birnbaum A, Bijur P, Shah S, Gleyzer A, Gallagher EJ. Ability of CT to alter decision making in elderly patients with acute abdominal pain. Am J Emerg Med 2004;22:270–2. [2] Graff LG, Robinson D. Abdominal pain and emergency department evaluation. Emerg Med Clin North Am 2001;19:123–36. [3] Daskalogiannaki M, Voloudaki A, Prassopoulos P, Magkanas E, Stefanaki K, Apostolaki E, et al. CT evaluation of mesenteric panniculitis: prevalence and associated diseases. AJR Am J Roentgenol 2000;174(2):427–31. [4] Sabate JM, Torrubia S, Maideu J, Franquet T, Monill JM, Perez C. Sclerosing mesenteritis: imaging findings in 17 patients. AJR Am J Roentgenol 1999;172:625–9. [5] Rosón N, Garriga V, Cuadrado M, Pruna X, Carbó S, Vizcaya S, et al. Sonographic findings of mesenteric panniculitis: correlation with CT and literature review. J Clin Ultrasound 2006;34:169–76. [6] Buyukkaya R, Buyukkaya A. Characteristic CT findings of mesenteric panniculit. Acta Gastroenterol Belg 2013;76(2):263. [7] Nicholson JA, Smith D, Diab M, Scott MH, Ann R. Mesenteric panniculitis in Merseyside: a case series and a review of the literature. Ann R Coll Surg Engl 2010;92:31–4.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
An unusual cause of acute abdominal pain: mesenteric panniculitis Mesenteric panniculitis is among the rare causes of abdominal pain, and its diagnosis is difficult for not only physicians but also radiologists. We aimed to present clinical and radiological findings of 2 patients admitted to the emergency department because of abdominal pain and diagnosed with mesenteric panniculitis, and discuss the relevant current literature. Emergency physicians who treat many patients with abdominal pain should remember mesenteric panniculitis when making differential diagnosis especially in patients with pain localized to left paraumbilical region. It should be known that computed tomography is highly useful in establishing the diagnosis. It is also important to remember that symptoms of most of those patients decline spontaneously and that conservative follow-up alone is sufficient for those cases, but surgical treatment may be the first choice in cases with progressively worsening symptoms. Abdominal pain is an important symptom accounting for 5% to 10% of emergency department (ED) admissions [1]. Hospitalization is required in 20% to 25% of cases, whereas 35% to 40% take the diagnosis of nonspecific abdominal pain because their diagnostic test results are all found to be normal and pain subsides on its own [2]. That high ratio of cases taking the diagnosis of nonspecific abdominal pain makes it mandatory for emergency physicians to be more careful. It will be helpful to know all possible causes of abdominal pain in starting specific treatment by reducing the number of patients taking the diagnosis of nonspecific abdominal pain. Mesenteric panniculitis (MP) is among the rare causes of abdominal pain, and its diagnosis is difficult for not only physicians but also radiologists. We aimed to present clinical and radiological findings of 2 patients admitted to ED because of abdominal pain and diagnosed with MP, and discuss the relevant current literature. A 36-year-old male patient was admitted to the ED because of abdominal pain. It was learned that his pain had started approximately 12 hours ago and that it was more prominent on his left side. There were no significant features in his medical history and in results of laboratory tests. Some tenderness and minimal guarding were present around the umbilicus. Computed tomographic (CT) scan showed a heterogenic mass lesion approximately 13 × 7 cm in dimension, at a density of − 77 HU with a well-defined hyperdense thin sheath, encircling superior mesenteric artery and superior mesenteric vein and causing minimal displacement of nearby intestinal segments (Fig. 1). The patient was diagnosed with MP and was taken to clinical and radiologic follow-up. A 59-year-old female patient was admitted to the ED because of complaints of abdominal pain and mild fever. It was learned that her pain had started approximately 5 hours ago and that it was more prominent on her left side. She had a history of hypertension. She was suffering from constipation periodically. Some tenderness was present
0735-6757/© 2015 Elsevier Inc. All rights reserved.
over the whole abdomen, and guarding was present in the left lower quadrant. Her blood pressure was 150/80 mm Hg, pulse rate was 74 beats per minute, and body temperature was 37.4°C. Results of her laboratory tests were normal. Abdominal ultrasound (USG) showed a minimally hyperechoic lesion with a normal vasculature in the mesentery on the left side. Computed tomography showed a heterogenic mass lesion approximately 9 × 5 cm in dimension, at a density of − 40 HU with a well-defined hyperdense thin sheath, encircling vascular structures and causing minimal displacement of nearby intestinal segments (Fig. 2). The patient was diagnosed with MP and was taken to clinical follow-up. It was seen on CT that her lesion became smaller on the 20th day when her symptoms also subsided. Mesenteric panniculitis is a rare disease characterized by a chronic nonspecific inflammation of mesenteric adipose tissue. Its exact cause is not known. It is suggested that causative factor may be infections, trauma, ischemia, malignancy, or vasculitis. It commonly affects small intestinal mesentery; but less commonly, colonic mesentery may also be affected. It generally originates from the root of mesentery at central plane and proceeds to the left of midline [3]. It is often seen between the ages of 50 and 60 years. It is 2 times more common in men [4]. Various symptoms may be seen in MP. The most commonly seen symptoms are abdominal pain, which is generally seen in the central region or on the upper quadrants, and an abdominal mass. Additionally, abdominal distention; loss of appetite; fever; nausea; vomiting; weight loss; diarrhea; constipation; and, less commonly, ascites and pleural or pericardial effusion may be seen. Symptoms may be progressive or periodic as well as self-limiting and subsiding in a short time [5]. Results of laboratory tests are commonly normal and do not help establish the diagnosis. Conventional abdominal radiographs and barium radiographs do not give any diagnostic information. Abdominal USG and CT are important studies to establish the diagnosis [4]. Diagnosis is commonly established by detection of CT criteria, although there are some cases diagnosed with USG in the literature; thus, CT alone is sufficient for the diagnosis [3,6,7]. Characteristic findings of MP on CT include adipose mass with well-defined borders, encircling superior mesenteric vessels, displacement of nearby bowel segments without any invasion, and nodular soft tissue lesions smaller than 5 mm in diameter [3]. There are some cases in whom surgical treatment was applied in the literature, whereas it was seen that symptoms of those patients did not decline but even worsened progressively. In a study, including 49 cases, performed by Daskalogiannaki et al [3], surgical treatment was applied to symptomatic cases only; and the other ones were followed up with periodic CT examinations. Corticosteroids and cyclophosphamide are suggested to be used in medical treatment of MP; however, some studies noting that it is a self-limiting disease and its symptoms decline spontaneously are also present [4]. Spontaneous remission of symptoms and improvement in CT findings were seen in our female patient; but
1328.e2
A. Buyukkaya et al. / American Journal of Emergency Medicine 33 (2015) 1328.e1–1328.e2
Fig. 1. A heterogenic mass lesion with a hyperdense thin sheath (arrow head), originating from mesenteric adipose tissue and encircling superior mesenteric artery (dashed arrow) and superior mesenteric vein (v), and accompanying normal lymph nodes (white arrow) are seen on axial (A) and sagittal (B) CT scans of our 36-year-old patient. Density difference between normal mesenteric adipose tissue and heterogenic inflamed mesenteric tissue is seen.
Fig. 2. Thin hyperdense sheath (arrow head) and vascular structures within the mass lesion are apparent on axial CT of our 59-year-old female patient.
our male patient was not as lucky as her, and his symptoms and radiological findings did not regress. In conclusion, emergency physicians who treat many patients with abdominal pain should remember MP when making differential diagnosis especially in patients with pain localized to left paraumbilical region. It should be known that CT is highly useful in establishing the diagnosis. It is also important to remember that symptoms of most of those patients decline spontaneously and conservative follow-up alone is sufficient for those cases, but surgical treatment may be the first choice in cases with progressively worsening symptoms.
Mehmet Ali Ozel Ramazan Buyukkaya Duzce University, School of Medicine, Department of Radiology Ayhan Sarıtas Duzce University, School of Medicine, Department of Emergency Medicine
http://dx.doi.org/10.1016/j.ajem.2015.02.050 References
Ayla Buyukkaya, MD Duzce Ataturk Government Hospital, Department of Radiology Corresponding author. Department of Radiology, Duzce Ataturk Goverment Hospital, Duzce, Turkey Tel.: +90 380 5292300 E-mail address: [email protected] Harun Gunes, MD Duzce University, School of Medicine, Department of Emergency Medicine Ismet Ozaydın Duzce University, School of Medicine, Department of General Surgery
[1] Esses D, Birnbaum A, Bijur P, Shah S, Gleyzer A, Gallagher EJ. Ability of CT to alter decision making in elderly patients with acute abdominal pain. Am J Emerg Med 2004;22:270–2. [2] Graff LG, Robinson D. Abdominal pain and emergency department evaluation. Emerg Med Clin North Am 2001;19:123–36. [3] Daskalogiannaki M, Voloudaki A, Prassopoulos P, Magkanas E, Stefanaki K, Apostolaki E, et al. CT evaluation of mesenteric panniculitis: prevalence and associated diseases. AJR Am J Roentgenol 2000;174(2):427–31. [4] Sabate JM, Torrubia S, Maideu J, Franquet T, Monill JM, Perez C. Sclerosing mesenteritis: imaging findings in 17 patients. AJR Am J Roentgenol 1999;172:625–9. [5] Rosón N, Garriga V, Cuadrado M, Pruna X, Carbó S, Vizcaya S, et al. Sonographic findings of mesenteric panniculitis: correlation with CT and literature review. J Clin Ultrasound 2006;34:169–76. [6] Buyukkaya R, Buyukkaya A. Characteristic CT findings of mesenteric panniculit. Acta Gastroenterol Belg 2013;76(2):263. [7] Nicholson JA, Smith D, Diab M, Scott MH, Ann R. Mesenteric panniculitis in Merseyside: a case series and a review of the literature. Ann R Coll Surg Engl 2010;92:31–4.
