University Hospitals Case Medical Center, Case Western Reserve University Cleveland, OH, United States
Muhammed M. Alikhan, MD1, Elie S. Al Kazzi, MD, MPH1, Christopher Linz, MD2 1University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH; 2Louis Stokes Cleveland VA Medical Center, Cleveland, OH
Introduction: The differential diagnosis for vague generalized abdominal pain is extremely broad. Oftentimes, as gastroenterologists we tend to focus first and foremost on luminal GI pathology. Here we present a rare cause of non-luminal, non-biliary abdominal pathology.
Case Description/Methods: A 57-year-old man presented to the hospital with a chief complaint of severe abdominal pain for 3 weeks. He described the pain as a generalized vague discomfort, which was intermittent and escalating over the past 6 months. It was associated with malaise, fatigue, early satiety, anorexia, and unintentional weight loss of 12 lbs. Initial evaluation consisted of contrasted abdominal CT imaging which showed numerous mildly enlarged rim-enhancing peri-portal, mesenteric, and aortocaval lymph nodes. Further imaging with a right upper quadrant ultrasound and a HIDA scan were unrevealing. The patient was then discharged with a diagnosis of possible chronic cholecystitis. Over the coming months, the patient lost an additional 35 lbs. Repeat CT demonstrated areas of central necrosis in the same cluster of lymph nodes visualized before, however these were significantly larger and more numerous (Figure 1). PET scan demonstrated multiple mesenteric masses with mild FDG hypermetabolic activity. The largest lesion measured 4.1x2.5 cm and showed spoke-wheel mesenteric thickening. Lymphoma was considered however ultimately an extensive workup was negative. The patient then underwent a laparoscopic cholecystectomy and mesenteric mass biopsy. Pathology demonstrated a calcified granuloma/hyalinized nodule in the gallbladder, along with extensive hyalinization and sclerosis in the mesenteric nodule.
Discussion: This patient was diagnosed with sclerosing mesenteritis. This is a spectrum of idiopathic inflammatory and fibrotic disorders that affect the mesentery. The etiology of this disorder can be related to trauma or abdominal surgery in 30-40% of cases. The most common presentation includes chronic abdominal pain and weight loss. Diagnosis is commonly made with cross-sectional imaging. Treatment depends on whether the mesenteric lesion is obstructive or not. For the former, a surgical bypass is usually indicated and for the latter, a combination of prednisone and tamoxifen can be initiated. Our patient’s symptoms improved on this regimen initially, but after worsening symptoms, a trial of azathioprine (AZT) was initiated. Aside from AZT, pentoxifylline, cyclophosphamide, thalidomide, and colchicine can be used in refractory cases.
Figure: Figure 1: CT non-contrast scan demonstrating multiple mesenteric masses along with central mesenteric thickening and haziness.
Muhammed Alikhan indicated no relevant financial relationships.
Elie Al Kazzi indicated no relevant financial relationships.
Christopher Linz indicated no relevant financial relationships.
Muhammed M. Alikhan, MD1, Elie S. Al Kazzi, MD, MPH1, Christopher Linz, MD2. P1985 - Sclerosing Mesenteritis in a Man Presenting With Vague Abdominal Pain, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.