Mesenteric panniculitis: A case report of a rare and tricky condition

Abstract text (incl. references and figure legends)

We present the case of an 84-year-old man known by our Emergency Department (ED) for a recent small bowel adhesiolysis without resections due to an internal hernia.

He referred to our ED complaining stipsi and vomit after 12 days from surgery, specifically four days from hospital discharge.

The physical examination showed a painful distended abdomen. Computed tomography (CT) showed a diffuse mesenteric and omental thickening associated to thickened small bowel walls without ischemic signs (Fig 1). Laboratory analysis showed slightly elevated white blood cell count and C-reactive protein. A positive test result for coronavirus was found without related symptoms.

The first approach was conservative with nasogastric tube and gastrografin administration. A slow progression of gastrografin turned out and prokinetics drugs started. After 10 days the patient complained of increased abdominal pain and vomit, and a new CT was performed showing bowel obstruction (Fig 2). An explorative laparotomy was performed. The small bowel appeared strictly adherent with fibrous nodules in the mesentery. The features were highly suggestive of malignant lesions. The extemporaneous histologic examination of the nodules was negative for tumors. Thirty centimeters of convoluted small bowel were resected, and the anastomosis was performed. After four days a new laparotomy was necessary due to fecal peritonitis. All the small bowel appeared even more convoluted and an ileostomy was made. The patient died after three days due to septic shock. Mesenteric panniculitis (MP) was diagnosed in the final histology.

MP can mimic different diseases. Diagnosis is extremely challenging, and the gold standard treatment is medical. Surgeons should be aware of mesenteric panniculitis to avoid misunderstanding. In our case report the MP's progression was fast after the first surgery for bowel obstruction. Coronavirus correlation cannot be excluded due to the fatty stranding described in both diseases.

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