Gastrointest Radiol 17:333-335 (1992)
Gastrointestinal
Radiology 9 Springer-VerlagNew York Inc. 1992
Retractile Mesenteritis with Colon and Retroperitoneum Involvement: CT Findings Shu-Hang Ng, Ho-Fai Wong, Sheung-Fat Ko, and Chung-Cheung Tsai Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Taipei, Taiwan, ROC
Abstract. We report a case of retractile mesenteritis which involved the rectosigmoid colon and extended into the retroperitoneum with ureteral obstruction. These complications are rare. The radiological features [including computed tomography (CT)] are described.
Key words: Mesentery, infection - Fibrosis - Computed tomography.
Retractile mesenteritis is an uncommon disease that occurs most often in late adult life with a male predominance. It is characterized by inflammation and fibrosis of the mesentery, usually resulting in a tumor-like mass. The etiology is unknown. The small bowel mesentery, especially at its root, is usually affected, though the sigmoid mesocolon can also be involved [1, 2]. On rare occasions, this disease involves the retroperitoneal area [2-5]. Herein, we present a case of retractile mesenteritis with colon and retroperitoneum involvement.
edges and serration. Small bowel series (Fig. 2) revealed an extrinsic mass lesion in the lower abdomen with compression and displacement of the adjacent bowel loops. Computed tomo* graphic (CT) scan (Fig. 3) disclosed an irregular soft-tissue mass in the mid-abdomen involving the mesentery and extending into the retroperitoneum with envelopment of the left iliac vessels and left distal ureter. CT scan also showed nodular densities in the mesentery, focal thickening of the small bowel, left hydronephrosis, and obscuration of the rectosigmoid colon. Left retrograde pyelogram (Fig. 4) revealed segmental narrowing of the distal ureter with tapered edges, indicating extrinsic compression and suggesting the probability of retroperitoneal fibrosis. At laparotomy, a fixed confluent mass adhered to the small bowel and the rectosigmoid colon was found. The peritoneum was firmly attached to the involved mesentery and could not be stripped off. Subtotal resection of the abdominal mass and segmental resection of the small bowel with end-to-end anastomosis were performed, following which the patient recovered uneventfully and the abdominal pain decreased. At 6 months' follow-up, the patient complained of occasional vague abdominal pain. Pathologic examination of the resected specimen revealed evidence of retractile mesenteritis at the mesentery with fibrosis of the bowel wall. Grossly, a thickened, retractile, and scirrhous mesentery that formed a pseudotumor was seen. The resected bowel loops were contracted and distorted due to local adhesion. Microscopically, extensive fibrosis and mild mononuclear cell infiltration were noted in the mesentery. The fibrosis also involved the bowel muscle and submucosa. The mesentery lymph nodes were infiltrated by the fibrosis as well.
Case Report A 60-year-old male was admitted to our hospital with a 2 month history of episodic severe abdominal pain. The patient also complained of nausea and anorexia. He denied alcohol abuse, significant abdominal trauma, or previous surgery. On physical examination, a poorly defined, deep and firm mass of about 10 cm in diameter was noted at the periumbilical region of the abdomen. The vital signs were normal. Laboratory tests revealed normal hematological and biochemical findings. Barium enema (Fig. 1) showed poor distensibility of the rectosigmoid colon with tapered
Address offprint requests to: Shu-Hang Ng, M.D., Department of Diagnostic Radiology, Chang Gung Memorial Hospital, 199, Tung Hwa North Road, Taipei, Taiwan, ROC
Discussion Mesentery isolated lipodystrophy, mesenteric panniculitis, and retractile mesenteritis are three descriptive terms used to characterize the pseudotumoral conditions of the mesentery based on histological differences. Histologically, three major features (fatty infiltration, chronic inflammation, and fibrosis) are present to some extent. When fatty infiltration is the dominant component, the disease is known as isolated lipodystrophy. When chronic inflammation is the main histologic finding, it implies mesenteric panniculitis. Retractile mesenteritis is
334
Fig. 1. Barium enema shows concentric narrowing in the rectosigmoid colon with tapered and serrated appearance. Fig. 2. Small-bowel film reveals an extrinsic mass with separation, kinking, and tethering of the bowel loops. Fig. 3. A C T scan demonstrates irregular soft-tissue mass involving the mesentery and retroperitoneum. A radiating pattern of linear densities emanates from the mass, representing thickened mesenteric neurovascular bundles. Bowel loop thickening, left hydroureter (arrowhead) and enlargement of mesenteric lymph nodes (arrow) due to fibrous infiltration are noted. B One centimeter caudal to A. CT scan shows obscuration of the rectosigmoid colon, and left ureter and iliac vessels, secondary to envelopment by the fibrous mass. Fig. 4. Left retrograde pyelogram shows a long tapered narrowing of the distal ureter, through which the ureteral catheter traversed without difficulty.
S.-H. Ng et al.: Retractile Mesenteritis
termed whenever fibrosis is the major feature, as in our case. From a practical standpoint, these different terms may describe various stages of a series of inflammatory changes affecting the mesentery [1, 6]. Retractile mesenteritis has been described in association with retroperitoneal fibrosis. The concurrence of retractile mesenteritis and retroperitoneal fibrosis has led to the hypothesis that they are the different expressions of a single process [1, 4, 7, 8]. The characteristic appearance of retractile mesenteritis on gastrointestinal series consists of separation and displacement of the small bowel loops by an extrinsic mass associated with tethering, kinking, and fixation of the involved loops. Less frequently, there is narrowing of the colon with a ragged mucosal surface [1, 6, 9, 10]. These findings were well demonstrated in our case. CT demonstrates retractile mesenteritis as a lo-
S.-H. Ng et al.: Retractile Mesenteritis
calized mass of fat density interspersed with softtissue density over the mesentery; thickened mesenteric neurovascular bundles, focal thickening of bowel wall, and calcifications are occasionally seen [1, 6, 9, 11]. The proportion of fat density and softtissue density on CT is likely to vary according to the proportion of fat and fibrous tissue in histological studies [6, 9, 12]. In the case reported here, CT revealed a mesenteric lesion that appeared as a mass of virtually soft-tissue density, consistent with predominance of fibrous tissue in the pathologic specimen. CT also demonstrated other classic CT features of retractile mesenteritis, including prominence of mesenteric neurovascular bundles and focal thickening of bowel loops. Moreover, mesenteric lymph node enlargement, rectosigmoid colon obscuration, a n d - - o f special interest--retroperitoneal involvement with envelopment of the iliac vessels and the left ureter causing ureteral obstruction were clearly depicted. The CT features of our case may document a common process underlying retractile mesenteritis and retroperitoneal fibrosis. References 1. Eisenberg RL. Disease of the appendix, peritoneum, and mesentery. In: Eisenberg RL, ed. Diagnostic imaging in internal medicine. New York: McGraw-Hill, 1985:696-706
335 2. Durst AL, Freund H, Rosenrnann E, Birnbaum D. Mesenteric panniculitis: review of the literature and presentation of cases. Surgery 1977;81:203-211 3. Bush RW, Hammar SP, Rudolph RH. Sclerosing mesenteritis: response to cyclophosphamide. Arch Intern Med 1986; 146:503-505 4. Kipfer RE, Moertel CG, Dahlin DC. Mesenteric lipodystrophy. Ann Intern Med 1974;80:582-588 5. Handelsman JC, Shelley WM. Mesenteric panniculitis. Arch Surg 1965;165:842-850 6. Mata JM, Inaraja L, Martin J, Olazabal A, Castilla MT. CT features of mesenteric panniculitis. J Computer Assisted Tomogr 1987;11:1021-1023 7. Harbrecht PJ. Variants of retroperitoneal fibrosis. Ann Surg 1966;165:388-401 8. Rogers CE, Demetrakopoulos N J, Hyamns V. Isolated lipodystrophy affecting the mesentery, the retroperitoneal area and the small intestine. Ann Surg 1961;153:277-282 9. Perez-Fontan FJ, Soler R, Sanchez J, Iglesias P, Sanjurgo P, Ruiz J. Retractile mesenteritis involving the colon: barium enema, sonographic and CT findings. A JR 1986;147:937-940 10. Adachi Y, Mori M, Enjoji M, Ueo H, Sugimachi K. Mesenteric panniculitis of the colon: review of the literature and report of two cases. Dis Colon Rectum 1987;30:962-966 11. Seigel RS, Kuhns LR, Borlaza GS, McCormick TL, Simmons JL. Computed tomography and angiography in ileal carcinoid tumor and retractile mesenteritis. Radiology 1980;134:437440 12. Katz ME, Heiken JP, Glazer HS, Lee KT. Intraabdominal panniculitis: clinical, radiographic, and CT features. A JR 1985; 145:293-296 Received: January 16, 1992: accepted: February 26, 1992
Gastrointestinal
Radiology 9 Springer-VerlagNew York Inc. 1992
Retractile Mesenteritis with Colon and Retroperitoneum Involvement: CT Findings Shu-Hang Ng, Ho-Fai Wong, Sheung-Fat Ko, and Chung-Cheung Tsai Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Taipei, Taiwan, ROC
Abstract. We report a case of retractile mesenteritis which involved the rectosigmoid colon and extended into the retroperitoneum with ureteral obstruction. These complications are rare. The radiological features [including computed tomography (CT)] are described.
Key words: Mesentery, infection - Fibrosis - Computed tomography.
Retractile mesenteritis is an uncommon disease that occurs most often in late adult life with a male predominance. It is characterized by inflammation and fibrosis of the mesentery, usually resulting in a tumor-like mass. The etiology is unknown. The small bowel mesentery, especially at its root, is usually affected, though the sigmoid mesocolon can also be involved [1, 2]. On rare occasions, this disease involves the retroperitoneal area [2-5]. Herein, we present a case of retractile mesenteritis with colon and retroperitoneum involvement.
edges and serration. Small bowel series (Fig. 2) revealed an extrinsic mass lesion in the lower abdomen with compression and displacement of the adjacent bowel loops. Computed tomo* graphic (CT) scan (Fig. 3) disclosed an irregular soft-tissue mass in the mid-abdomen involving the mesentery and extending into the retroperitoneum with envelopment of the left iliac vessels and left distal ureter. CT scan also showed nodular densities in the mesentery, focal thickening of the small bowel, left hydronephrosis, and obscuration of the rectosigmoid colon. Left retrograde pyelogram (Fig. 4) revealed segmental narrowing of the distal ureter with tapered edges, indicating extrinsic compression and suggesting the probability of retroperitoneal fibrosis. At laparotomy, a fixed confluent mass adhered to the small bowel and the rectosigmoid colon was found. The peritoneum was firmly attached to the involved mesentery and could not be stripped off. Subtotal resection of the abdominal mass and segmental resection of the small bowel with end-to-end anastomosis were performed, following which the patient recovered uneventfully and the abdominal pain decreased. At 6 months' follow-up, the patient complained of occasional vague abdominal pain. Pathologic examination of the resected specimen revealed evidence of retractile mesenteritis at the mesentery with fibrosis of the bowel wall. Grossly, a thickened, retractile, and scirrhous mesentery that formed a pseudotumor was seen. The resected bowel loops were contracted and distorted due to local adhesion. Microscopically, extensive fibrosis and mild mononuclear cell infiltration were noted in the mesentery. The fibrosis also involved the bowel muscle and submucosa. The mesentery lymph nodes were infiltrated by the fibrosis as well.
Case Report A 60-year-old male was admitted to our hospital with a 2 month history of episodic severe abdominal pain. The patient also complained of nausea and anorexia. He denied alcohol abuse, significant abdominal trauma, or previous surgery. On physical examination, a poorly defined, deep and firm mass of about 10 cm in diameter was noted at the periumbilical region of the abdomen. The vital signs were normal. Laboratory tests revealed normal hematological and biochemical findings. Barium enema (Fig. 1) showed poor distensibility of the rectosigmoid colon with tapered
Address offprint requests to: Shu-Hang Ng, M.D., Department of Diagnostic Radiology, Chang Gung Memorial Hospital, 199, Tung Hwa North Road, Taipei, Taiwan, ROC
Discussion Mesentery isolated lipodystrophy, mesenteric panniculitis, and retractile mesenteritis are three descriptive terms used to characterize the pseudotumoral conditions of the mesentery based on histological differences. Histologically, three major features (fatty infiltration, chronic inflammation, and fibrosis) are present to some extent. When fatty infiltration is the dominant component, the disease is known as isolated lipodystrophy. When chronic inflammation is the main histologic finding, it implies mesenteric panniculitis. Retractile mesenteritis is
334
Fig. 1. Barium enema shows concentric narrowing in the rectosigmoid colon with tapered and serrated appearance. Fig. 2. Small-bowel film reveals an extrinsic mass with separation, kinking, and tethering of the bowel loops. Fig. 3. A C T scan demonstrates irregular soft-tissue mass involving the mesentery and retroperitoneum. A radiating pattern of linear densities emanates from the mass, representing thickened mesenteric neurovascular bundles. Bowel loop thickening, left hydroureter (arrowhead) and enlargement of mesenteric lymph nodes (arrow) due to fibrous infiltration are noted. B One centimeter caudal to A. CT scan shows obscuration of the rectosigmoid colon, and left ureter and iliac vessels, secondary to envelopment by the fibrous mass. Fig. 4. Left retrograde pyelogram shows a long tapered narrowing of the distal ureter, through which the ureteral catheter traversed without difficulty.
S.-H. Ng et al.: Retractile Mesenteritis
termed whenever fibrosis is the major feature, as in our case. From a practical standpoint, these different terms may describe various stages of a series of inflammatory changes affecting the mesentery [1, 6]. Retractile mesenteritis has been described in association with retroperitoneal fibrosis. The concurrence of retractile mesenteritis and retroperitoneal fibrosis has led to the hypothesis that they are the different expressions of a single process [1, 4, 7, 8]. The characteristic appearance of retractile mesenteritis on gastrointestinal series consists of separation and displacement of the small bowel loops by an extrinsic mass associated with tethering, kinking, and fixation of the involved loops. Less frequently, there is narrowing of the colon with a ragged mucosal surface [1, 6, 9, 10]. These findings were well demonstrated in our case. CT demonstrates retractile mesenteritis as a lo-
S.-H. Ng et al.: Retractile Mesenteritis
calized mass of fat density interspersed with softtissue density over the mesentery; thickened mesenteric neurovascular bundles, focal thickening of bowel wall, and calcifications are occasionally seen [1, 6, 9, 11]. The proportion of fat density and softtissue density on CT is likely to vary according to the proportion of fat and fibrous tissue in histological studies [6, 9, 12]. In the case reported here, CT revealed a mesenteric lesion that appeared as a mass of virtually soft-tissue density, consistent with predominance of fibrous tissue in the pathologic specimen. CT also demonstrated other classic CT features of retractile mesenteritis, including prominence of mesenteric neurovascular bundles and focal thickening of bowel loops. Moreover, mesenteric lymph node enlargement, rectosigmoid colon obscuration, a n d - - o f special interest--retroperitoneal involvement with envelopment of the iliac vessels and the left ureter causing ureteral obstruction were clearly depicted. The CT features of our case may document a common process underlying retractile mesenteritis and retroperitoneal fibrosis. References 1. Eisenberg RL. Disease of the appendix, peritoneum, and mesentery. In: Eisenberg RL, ed. Diagnostic imaging in internal medicine. New York: McGraw-Hill, 1985:696-706
335 2. Durst AL, Freund H, Rosenrnann E, Birnbaum D. Mesenteric panniculitis: review of the literature and presentation of cases. Surgery 1977;81:203-211 3. Bush RW, Hammar SP, Rudolph RH. Sclerosing mesenteritis: response to cyclophosphamide. Arch Intern Med 1986; 146:503-505 4. Kipfer RE, Moertel CG, Dahlin DC. Mesenteric lipodystrophy. Ann Intern Med 1974;80:582-588 5. Handelsman JC, Shelley WM. Mesenteric panniculitis. Arch Surg 1965;165:842-850 6. Mata JM, Inaraja L, Martin J, Olazabal A, Castilla MT. CT features of mesenteric panniculitis. J Computer Assisted Tomogr 1987;11:1021-1023 7. Harbrecht PJ. Variants of retroperitoneal fibrosis. Ann Surg 1966;165:388-401 8. Rogers CE, Demetrakopoulos N J, Hyamns V. Isolated lipodystrophy affecting the mesentery, the retroperitoneal area and the small intestine. Ann Surg 1961;153:277-282 9. Perez-Fontan FJ, Soler R, Sanchez J, Iglesias P, Sanjurgo P, Ruiz J. Retractile mesenteritis involving the colon: barium enema, sonographic and CT findings. A JR 1986;147:937-940 10. Adachi Y, Mori M, Enjoji M, Ueo H, Sugimachi K. Mesenteric panniculitis of the colon: review of the literature and report of two cases. Dis Colon Rectum 1987;30:962-966 11. Seigel RS, Kuhns LR, Borlaza GS, McCormick TL, Simmons JL. Computed tomography and angiography in ileal carcinoid tumor and retractile mesenteritis. Radiology 1980;134:437440 12. Katz ME, Heiken JP, Glazer HS, Lee KT. Intraabdominal panniculitis: clinical, radiographic, and CT features. A JR 1985; 145:293-296 Received: January 16, 1992: accepted: February 26, 1992
