Gastroenterology Gastroenterology

ISSN 1007-9327 CN 14-1219/R

World Journal of Gastroenterology

World Journal of

Gastroenterology Volume 15 Number 30 August 14, 2009

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2009

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World Journal of

Gastroenterology Indexed and Abstracted in: Current Contents®/Clinical Medicine, Science Citation Index Expanded (also known as SciSearch®) and Journal Citation Reports/Science Edition, Index Medicus, MEDLINE and PubMed, Chemical Abstracts, EMBASE/Excerpta Medica, Abstracts Journals, PubMed Central, Digital Object Identifier, CAB Abstracts and Global Health. ISI, Thomson Reuters, 2008 Impact Factor: 2.081 (32/55 Gastroenterology and Hepatology).

Volume 15 Number 30 August 14, 2009

World J Gastroenterol 2009 August 14; 15(30): 3713-3840

A Weekly Journal of Gastroenterology and Hepatology

ISSN 1007-9327 CN 14-1219/R Local Post Offices Code No. 82-261

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World Journal of

Gastroenterology Weekly Established in October 1995


Contents EDITORIAL

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百世登

Baishideng™©

Management of hepatitis C virus infection in HIV�� /HCV co-infected patients: �� Clinical review Singal AK��,�� Anand �� BS

TOPIC HIGHLIGHT

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Endoscopic management of biliary strictures after liver transplantation Williams� ED,� �� Draganov� �� PV

REVIEW

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Disparities in colorectal cancer in African-Americans vs Whites: Before and after diagnosis Dimou A, Syrigos KN, Saif MW

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Transition of children with inflammatory bowel disease: Big task, little evidence El-Matary�� W

ORIGINAL ARTICLES

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Characterization of focal liver lesions with SonoVue®-enhanced sonography: International multicenter-study in comparison to CT and MRI Trillaud H, Bruel JM, Valette PJ, Vilgrain V, Schmutz G, Oyen R, Jakubowski W, Danes J, Valek V, Greis C

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Lentivirus-mediated shRNA interference targeting STAT3 inhibits human pancreatic cancer cell invasion Yang G, Huang C, Cao J, Huang KJ, Jiang T, Qiu ZJ

BRIEF ARTICLES

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Reinterpretation of histology of proximal colon polyps called hyperplastic in 2001 Khalid O, Radaideh S, Cummings OW, O’Brien MJ, Goldblum JR, Rex DK

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No association between phosphatase and tensin homolog genetic polymorphisms and colon cancer Phillips LS, Thompson CL, Merkulova A, Plummer SJ, Tucker TC, Casey G, Li L

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IL-10 and TNF-a promoter haplotypes are associated with childhood Crohn’s disease location Sanchez R, Levy E, Costea F, Sinnett D

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Superiority of split dose midazolam as conscious sedation for outpatient colonoscopy Lee H, Kim JH

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Acute transient hepatocellular injury in cholelithiasis and cholecystitis without evidence of choledocholithiasis Chang CW, Chang WH, Lin CC, Chu CH, Wang TE, Shih SC

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Contents

Volume 15 Number 30 August 14, 2009 3793

Lymphovascular invasion in rectal cancer following neoadjuvant radiotherapy: A retrospective cohort study Du CZ, Xue WC, Cai Y, Li M, Gu J

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Methylation of PTCH1a gene in a subset of gastric cancers Du P, Ye HR, Gao J, Chen W, Wang ZC, Jiang HH, Xu J, Zhang JW, Zhang JC, Cui L

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Connective tissue growth factor hammerhead ribozyme attenuates human hepatic stellate cell function Gao RP, Brigstock DR

CASE REPORT

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Adalimumab in ulcerative colitis: Two cases of mucosal healing and clinical response at two years Barreiro-de Acosta�� M, �� Lorenzo�� A, �� Dominguez-Muñoz�� JE

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Sepsis caused by endoscopic clipping for colonic diverticular bleeding: A rare complication Kume K, Yamasaki M, Yoshikawa I

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Duodenal obstruction after successful embolization for duodenal diverticular hemorrhage: A case report Kwon�� YJ��, Kim�� JH��, �� Kim�� SH��, �� Kim� �� BS��, �� Kim�� HU��, �� Choi� �� EK��, �� Jeong�� IH

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Percutaneous paraumbilical embolization as an unconventional and successful treatment for bleeding jejunal varices Lim LG, Lee YM, Tan L, Chang S, Lim SG

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Mesenteric panniculitis: Various presentations and treatment regimens Issa I, Baydoun H

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Cavernous hemangioma arising from the gastro-splenic ligament: A case report Chin�� KF, Khair�� G, �� Babu� PS, �� Morgan� �� DR

LETTERS TO THE EDITOR 3834

“Anti-HBc alone” in human immunodeficiency virus-positive and immunosuppressed lymphoma patients Koo YX, Tan DSW, Tan IBH, Quek R, Tao M, Lim ST

ACKNOWLEDGMENTS

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Acknowledgments to reviewers of World Journal of Gastroenterology

APPENDIX

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Meetings

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Instructions to authors

I-VII

Editorial Board

FLYLEAF INSIDE BACK COVER

Online Submissions

INSIDE FRONT COVER

Online Submissions

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Contents


INTRODUCTION

World Journal of Gastroenterology is an international, open-access, peer-reviewed, and multidisciplinary weekly journal that serves gastroenterologists and hepatologists. The biggest advantage of the open access model is that it provides free, full-text articles in PDF and other formats for experts and the public without registration, which eliminates the obstacle that traditional journals possess and usually delays the speed of the propagation and communication of scientific research results. The open access model has been proven to be a true approach that may achieve the ultimate goal of the journals, i.e. the maximization of the values of the readers, the authors and the society. Maximization of the value of the readers can be comprehended in two ways. First, the journal publishes articles that can be directly read or downloaded free of charge at any time, which attracts more readers. Second, the readers can apply the knowledge in clinical practice without delay after reading and understanding the information in their fields. In addition, the readers are encouraged to propose new ideas based on those of the authors, or to provide viewpoints that are different from those of the authors. Such discussions or debates among different schools of thought will definitely boost advancements and developments in the fields. Maximization of the value of the authors refers to the fact that these journals provide a platform that promotes the speed of propagation and communication to a maximum extent. This is also what the authors really need. Maximization of the value of the society refers to the maximal extent of the social influences and impacts produced by the high quality original articles published in the journal.�� This is also the main purpose of many journals around the world.

EDITORS FOR THIS ISSUE

Responsible Assistant Editor: Xiao-Fang Liu Responsible Electronic Editor: De-Hong Yin Proofing Editor-in-Chief: Lian-Sheng Ma

NAME OF JOURNAL World Journal of Gastroenterology RESPONSIBLE INSTITUTION Department of Science and Technology of Shanxi Province SPONSOR Taiyuan Research and Treatment Center for Digestive Diseases, 77 Shuangta Xijie, Taiyuan 030001, Shanxi Province, China EDITING Editorial Board of World Journal of Gastroenterology, Room 903, Building D, Ocean International Center, No.62 Dongsihuan Zhonglu, Chaoyang District, Beijing 100025, China Telephone: +86-10-59080039 Fax: +86-10-85381893 E-mail: [email protected] http://www.wjgnet.com PUBLISHING The WJG Press and Beijing Baishideng BioMed Scientific Co., Ltd.. Room 903, Building D, Ocean International Center, No.62 Dongsihuan Zhonglu, Chaoyang District, Beijing 100025, China Telephone: +86-10-59080039 Fax: +86-10-85381893 E-mail: [email protected] http://www.wjgnet.com PRINTING Beijing Kexin Printing House OVERSEAS DISTRIBUTOR Beijing Bureau for Distribution of Newspapers and Journals (Code No. 82-261) China International Book Trading Corporation PO Box 399, Beijing, China (Code No. M4481) PUBLICATION DATE August 14, 2009 EDITOR-IN-CHIEF Lian-Sheng Ma, Beijing

SUBSCRIPTION RMB 50 Yuan for each issue, RMB 2400 Yuan for one year CSSN ISSN 1007-9327 CN 14-1219/R HONORARY EDITORS-IN-CHIEF Montgomery Bissell, San Francisco James L Boyer, New Haven Chao-Long Chen, Kaohsiung Ke-Ji Chen, Beijing Li-Fang Chou, Taipei Jacques V Dam, Stanford Martin H Floch, New Haven Guadalupe Garcia-Tsao, New Haven Zhi-Qiang Huang, Beijing Shinn-Jang Hwang, Taipei Ira M Jacobson, New York Derek Jewell, Oxford Emmet B Keeffe, Palo Alto Min-Liang Kuo, Taipei Nicholas F LaRusso, Rochester Jie-Shou Li, Nanjing Geng-Tao Liu, Beijing Lein-Ray Mo, Tainan Bo-Rong Pan, Xi'an Fa-Zu Qiu, Wuhan Eamonn M Quigley, Cork David S Rampton, London Rafiq A Sheikh, Sacramento Rudi Schmid, Kentfield[1] Nicholas J Talley, Rochester Sun-Lung Tsai, Young-Kang City Guido NJ Tytgat, Amsterdam Hsiu-Po Wang, Taipei Jaw-Ching Wu, Taipei Meng-Chao Wu, Shanghai Ming-Shiang Wu, Taipei Jia-Yu Xu, Shanghai Ta-Sen Yeh, Taoyuan Ming-Lung Yu, Kaohsiung STRATEGY ASSOCIATE EDITORS-IN-CHIEF Peter Draganov, Florida Ronnie Fass, Tucson Hugh J Freeman, Vancouver John P Geibel, New Haven Maria C Gutiérrez-Ruiz, México

Responsible Science Editor: Lai-Fu Li Proofing Editorial Office Director: Jian-Xia Cheng

Kazuhiro Hanazaki, Kochi Akio Inui, Kagoshima Kalpesh Jani, Vadodara Sanaa M Kamal, Cairo Ioannis E Koutroubakis, Heraklion Jose JG Marin, Salamanca Javier S Martin, Punta del Este Natalia A Osna, Omaha Jose Sahel, Marseille Ned Snyder, Galveston Nathan Subramaniam, Brisbane Wei Tang, Tokyo Alan BR Thomson, Edmonton Paul Joseph Thuluvath, Baltimore James F Trotter, Denver Shingo Tsuji, Osaka Harry HX Xia, Hanover Yoshio Yamaoka, Houston Jesue K Yamamoto-Furusho, México ASSOCIATE EDITORS-IN-CHIEF Gianfranco D Alpini, Temple Bruno Annibale, Roma Roger William Chapman, Oxford Chi-Hin Cho, Hong Kong Alexander L Gerbes, Munich Shou-Dong Lee, Taipei Walter Edwin Longo, New Haven You-Yong Lu, Beijing Masao Omata, Tokyo EDITORIAL OFFICE Director: Jian-Xia Cheng, Beijing Deputy Director: Jian-Zhong Zhang, Beijing LANGUAGE EDITORS Director: Jing-Yun Ma, Beijing Deputy Director: Xian-Lin Wang, Beijing MEMBERS Gianfranco D Alpini, Temple BS Anand, Houston Manoj Kumar, Nepal Patricia F Lalor, Birmingham Ming Li, New Orleans Margaret Lutze, Chicago Sabine Mihm, Göttingen Francesco Negro, Genève Bernardino Rampone, Siena Richard A Rippe, Chapel Hill Stephen E Roberts, Swansea

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COPY EDITORS Gianfranco D Alpini, Temple Sujit Kumar Bhattacharya, Kolkata Filip Braet, Sydney Kirsteen N Browning, Baton Rouge Radha K Dhiman, Chandigarh John Frank Di Mari, Texas Shannon S Glaser, Temple Eberhard Hildt, Berlin Patricia F Lalor, Birmingham Ming Li, New Orleans Margaret Lutze, Chicago MI Torrs, Jaén Sri Prakash Misra, Allahabad Giovanni Monteleone, Rome Giovanni Musso, Torino Valerio Nobili, Rome Osman Cavit Ozdogan, Istanbul Francesco Perri, San Giovanni Rotondo Thierry Piche, Nice Bernardino Rampone, Siena Richard A Rippe, Chapel Hill Ross C Smith, Sydney Daniel Lindsay Worthley, Bedford George Y Wu, Farmington Jian Wu, Sacramento COPYRIGHT © 2009 Published by The WJG Press and Baishideng. All rights reserved; no part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior permission of WJG. Authors are required to grant WJG an exclusive licence to publish. SPECIAL STATEMENT All articles published in this journal represent the viewpoints of the authors except where indicated otherwise. INSTRUCTIONS TO AUTHORS Full instructions are available online at http://www.wjgnet.com/wjg/help/ instructions.jsp. If you do not have web access please contact the editorial office. ONLINE SUBMISSION http://wjg.wjgnet.com

Online Submissions: wjg.wjgnet.com [email protected] doi:10.3748/wjg.15.3827

World J Gastroenterol 2009 �� August� 14; �� 15(30): �� 3827-3830 �� World Journal of Gastroenterology ISSN 1007-9327 © 2009 The WJG Press and Baishideng. All rights reserved.

CASE REPORT

Mesenteric panniculitis: Various presentations and treatment regimens

Iyad Issa, Hassan Baydoun Iyad Issa, Hassan Baydoun, Department of Gastroenterology & Hepatology, Rafik Hariri University Hospital, Beirut 2034-7304, Lebanon Author contributions: Issa I and Baydoun H both contributed equally to the paper. Correspondence to: Dr. Iyad Issa, Head of Department of Gastroenterology & Hepatology, Rafik Hariri University Hospital, Beirut 2034-7304, Lebanon. [email protected] Telephone: +961-3260908 Fax: +961-1737377 Received: March 14, 2009 Revised: June 24, 2009 Accepted: July 1, 2009 Published online: August 14, 2009

Abstract Mesenteric panniculitis is a rare, benign and chronic fibrosing inflammatory disease that affects the adipose tissue of the mesentery of the small intestine and colon. The specific etiology of the disease is unknown. The diagnosis is suggested by computed tomography and is usually confirmed by surgical biopsies. Treatment is empirical and based on a few selected drugs. Surgical resection is sometimes attempted for definitive therapy, although the surgical approach is often limited. We report two cases of mesenteric panniculitis with two different presentations and subsequently varying treatment regimens. Adequate response was obtained in both patients. We present details of these cases as well as a literature review to compare various presentations, etiologies and potential treatment modalities. © 2009 The WJG Press and Baishideng. All rights reserved.

Key words: Mesentery; Panniculitis; Colon; Computed tomography; Fibrosis; Inflammation Peer reviewer: Nikolaus Gassler, Professor, Institute of Pathology, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany

Issa I, Baydoun H. Mesenteric panniculitis: Various presentations and treatment regimens. World J Gastroenterol 2009; 15(30): 3827-3830 Available from: URL: http://www. wjgnet.com/1007-9327/15/3827.asp DOI: http://dx.doi. org/10.3748/wjg.15.3827

INTRODUCTION Mesenteric panniculitis is an acute benign fibrosing

and inflammatory condition that involves the adipose tissue of the mesentery. It was first described by Jura in 1924 as “retractile mesenteritis” and further labeled as “mesenteric panniculitis” by Odgen later in the 1960s. Currently, it has several names: sclerosing mesenteritis, mesenteric lipodystrophy, mesenteric sclerosis, retractile mesenteritis, mesenteric Weber-Christian disease, liposclerotic mesenteritis, lipomatosis and lipogranuloma of the mesentery [1]. It can be categorized according to three pathological changes: chronic nonspecific inflammation, fat necrosis and fibrosis[2]. This varied terminology has caused considerable confusion, but the condition can now be evaluated as a single disease with two pathological subgroups. If inflammation and fat necrosis predominate over fibrosis, the condition is known as mesenteric panniculitis, and when fibrosis and retraction predominate, the result is retractile mesenteritis. The overall presence of some degree of fibrosis makes the pathological term sclerosing mesenteritis more accurate in most cases[3].

CASE REPORT Case 1 A 68-year-old female patient was admitted to our hospital with a 1-wk history of recurrent, right-sided abdominal pain, moderate in intensity, which lasted for many hours, and was associated with nausea but not vomiting. She had no change in bowel habits and was passing flatus and stools. Her past medical history included hypertension for 10 years, dyslipidemia and diffuse diverticulosis with recurrent episodes of diverticulitis that necessitated left partial colectomy with primary anastomosis 4 years ago. As a result of disease progression, she underwent open total colectomy with an ileorectal anastomosis. She presented at 6 wk after surgery. Her medication history included valsartan, propranolol, fenofibrate, laxatives, antispasmodics and fibers. She had no known allergies, no significant family history, and a review of her systems was unremarkable. Upon physical examination, the patient appeared well, in no acute distress and had stable vital signs. The remainder of the examination was unremarkable, except for moderate tenderness upon superficial and deep palpation of the abdomen (right quadrant, and a feeling of an ill-defined mass. Her laboratory profile was normal.

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Figure 1 High resolution computed tomography scan. A: Smooth thickening evident between small bowels suggestive of a large inflammatory mass (arrow); B: Almost total disappearance of the inflammatory mass; C: A mass in jejunal compartment suggestive of mesenteric panniculitis. arrow shows a 9 mm lymph node; D: Complete disappearance of the previously described mass.

Computed tomography (CT) of the abdomen was performed using reconstructed slice thickness of 5 mm after oral and intravenous (iv) contrast administration, which showed a focal increase in density of the mesenteric fat with stranding in the supra-umbilical region, which was most probably inflammatory in origin and suggestive of mesenteric panniculitis (Figure 1A). This finding was surprising, especially in the light of a previous laparotomy a few weeks before, which revealed a clean abdomen. The patient was started on prednisone 40 mg daily and was followed-up closely. Her symptoms gradually decreased in intensity and pain disappeared totally within 8 wk. Follow up CT 3 mo later showed a decrease in the mesenteric mass by 80%-90% (Figure 1B). However, she could not tolerate the steroids much longer because of peripheral neuropathy and hyperglycemia, therefore, she was switched to colchicine 100 mg daily orally. Her status was reassessed 6 mo later, and CT showed persistence of the positive response and absence of the mass. Currently, she has been off treatment for 6 mo without recurrence of any symptoms. Case 2 A 74-year-old female patient presented to our care because of a chronic history of abdominal discomfort. Her symptoms were episodic and included discomfort that lasted a few minutes, which was associated with vomiting and followed by syncope of a few seconds duration. She had ho abdominal pain, no change in bowel habits or hematochezia and no weight loss.

Her past medical histor y was significant for hypertension, herniated vertebral disc, peptic ulcer disease and diverticulosis. At the time of presentation, the patient was taking perindopril, levothyroxine and risedronate. She had no known allergies to any medication or substance, and no significant family history. A review of her systems was notable for nausea and occasional vomiting. Upon physical examination, she appeared well, in no acute distress and had stable vital signs. Laboratory data revealed a normal complete blood count, blood chemistry and coagulation profile. Upper gastrointestinal endoscopy was performed and showed mild non-erosive gastritis with a positive urease test for Helicobacter pylori. Spiral CT of the abdomen and pelvis, using a reconstructed slice thickness of 5 mm after oral and iv contrast administration showed a hazy, veil-like hyperattenuation of the mesenteric root and leaves, primarily seen in the jejunum. The radiological picture was highly suggestive of mesenteric panniculitis (Figure 1C). Interspersed subcentimetric mesenteric lymph nodes were also seen. The largest one was located in a lower jejunal mesenteric leaflet of the left lower quadrant, and reached 9 mm in the short axis. The rest of the examination was normal. Treatment was started with 40 mg prednisone once daily and she was discharged home. She had an excellent response that was demonstrated in her followup CT scan 2 mo later. The previously described increased density of the peri-pancreatic and mesenteric fat caused by panniculitis was no longer present. The

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Issa ��I et al . Review of mesenteric panniculitis

mesenteric fat showed normal density with no evidence of inflammation or retroperitoneal or mesenteric adenopathy. At this time, she had no abdominal complaints. She was still taking the same dose of steroids. Three months later, she was readmitted with acute herpes zoster infection. Treatment had to be aborted and prednisone was slowly tapered until discontinuation, and no other treatment was initiated. She was followed-up closely with no recurrence of symptoms and persistent radiological remission, as shown by CT repeated at 2 mo after steroid discontinuation (Figure 1D).

DISCUSSION Mesenteric panniculitis is a rare inflammatory condition that is characterized by chronic and nonspecific inflammation of the adipose tissue of the intestinal mesentery. So far, 130 cases have been reported in the literature under several names: retractile mesenteritis, sclerosing mesenteritis, liposclerotic mesenteritis, isolated lipodystrophy of the mesentery, mesenteric lipomatosis, and lipogranuloma of the mesentery, and mesenteric manifestations of Weber-Christian disease[4,5]. Most studies have indicated that the disease is more common in men, with a male/female ratio of 2-3:1, and several reports have indicated it to be more common in Caucasian men. Incidence increases with age, and pediatric cases are exceptional, probably because children have less mesenteric fat when compared to adults[6]. T h e p a t h o g e n i c m e ch a n i s m o f m e s e n t e r i c panniculitis seems to be a nonspecific response to a wide variety of stimuli. Although various causal factors have been identified, the precise etiology remains unknown. Emory et al[2] have reported a series in which 84% of patients had a history of abdominal trauma or surgery. Furthermore, the disease is related to other factors, such as mesenteric thrombosis, mesenteric arteriopathy, drugs, thermal or chemical injuries, vasculitis, avitaminosis, autoimmune disease, retained suture material, pancreatitis, bile or urine leakage, hypersensitivity reactions, and even bacterial infection[6,7]. Other factors, such as gallstones, coronary disease, cirrhosis, abdominal aortic aneurysm, peptic ulcer, or chylous ascitis, have also been linked to this disease[8]. More recent studies have shown a strong relationship between tobacco consumption and panniculitis[7]. Retractile mesenteritis has been associated with a number of malignant diseases such as lymphoma, lung cancer, melanoma, colon cancer, renal cell cancer, myeloma, gastric carcinoma, chronic lymphocytic leukemia, Hodgkin’s disease, large cell lymphoma (giant-cell carcinoma), carcinoid tumor, and thoracic mesothelioma[2,6,7,9-11]. In over 90% of cases, mesenteric panniculitis involves the small-bowel mesentery, although it may sometimes involve the sigmoid mesentery[10]. On rare occasions, it may involve the mesocolon, peripancreatic region, omentum, retroperitoneum or pelvis[12]. The mean clinical progression is usually 6 mo,

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Table 1 Differential diagnosis of mesenteric panniculitis Lymphoma Lymphosarcoma Carcinoid tumors Desmoid tumors Infectious diseases (tuberculosis and histoplasmosis) Amyloidosis Peritoneal mesothelioma Desmoplastic carcinoma metastases Whipple’s disease Chronic inflammation due to foreign body Reaction to adjacent cancer or chronic abscess Retroperitoneal sarcoma

ranging from 2 wk to 16 years. The disease is often asymptomatic. When present, clinical symptoms vary greatly, and may include anorexia, abdominal pain, abdominal fullness, nausea, pyrexia, and weight loss[11]. On occasions, the disease may also present with merely a single or multiple palpable masses. Exceptionally, rectal bleeding, jaundice, gastric outlet obstruction, and even acute abdomen have been reported[2,9,12]. Such a wide variety of manifestations means that a large number of illnesses must be considered for differential diagnosis, therefore, careful assessment by the treating physician is strongly advised (Table 1). Histologically, the disease progresses in three stages[6]. The first stage is mesenteric lipodystrophy, in which a layer of foamy macrophages replaces mesenteric fat. Acute inflammatory signs are minimal or nonexistent; the disease tends to be clinically asymptomatic and prognosis is good. In the second stage, termed mesenteric panniculitis, histology reveals an infiltrate made up of plasma cells and a few polymorphonuclear leukocytes, foreign-body giant cells, and foamy macrophages. Most common symptoms include fever, abdominal pain, and malaise. The final stage is retractile mesenteritis, which shows collagen deposition, fibrosis, and inflammation. Collagen deposition leads to scarring and retraction of the mesentery, which in turn, leads to the formation of abdominal masses and obstructive symptoms. The exact diagnosis is often difficult and is usually made by finding one of three major pathological features: fibrosis, chronic inflammation, or fatty infiltration of the mesentery. To some extent, all three components are present in most cases[13]. Blood tests tend to be within the normal range. Neutrophilia, increased erythrocyte sedimentation rate or anemia have been reported occasionally in the retractile mesenteritis stage[6]. Some reports even go as far as stating that few or none of the patients with mesenteric panniculitis can be diagnosed correctly before operation [4,14] . However, with the advent of imaging technology like high-resolution CT or magnetic resonance imaging, distinguishing mesenteric panniculitis from other mesenteric diseases with similar imaging features such as carcinomatosis, carcinoid tumor, lymphoma, desmoid tumor, and mesenteric edema seems possible and feasible [15,16]. The imaging appearance of mesenteric

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panniculitis varies depending on the predominant tissue component (fat necrosis, inflammation, or fibrosis)[17]. It is visualized usually as a heterogeneous mass with a large fat component and interposed linear bands with soft tissue density in cases of mesenteric panniculitis, or as a homogeneous mass of soft tissue density in cases of retractile mesenteritis. Colonoscopy is usually unrevealing, since mesenteric panniculitis is extrinsic to the bowel. Paracentesis that reveals inflammatory cell populations without mitotic figures can also aid diagnosis. Mesenteric panniculitis resolves spontaneously in most cases, however, palpable masses may often be found between 2 and 11 years after diagnosis, especially in patients with associated comorbidity [6]. In such cases, several types of treatment have been proposed but no consensus has been established. In general, treatment has been reserved for symptomatic cases. Incidental masses may be observed and left untreated. Therapy is individualized on a case by case basis. Treatment may be attempted with a variety of drugs including steroids, thalidomide, cyclophosphamide, progesterone, colchicine, azathioprine, tamoxifen, antibiotics and emetine, or radiotherapy, with different degrees of success [18-20]. Surgery may be attempted if medical therapy fails or in the presence of lifethreatening complications such as bowel obstruction or perforation[5]. Our two cases showed different presentations: one was chronic and compatible with most published data, and the other was post-surgical, which makes it a very rare occurrence. Two different treatment regimens were used successfully in both cases. This should encourage us to review our approach to those cases that are always considered to be surgical, and leave room for medical treatment, which may be more effective than previously noted. In conclusion, mesenteric panniculitis is a rare clinical entity that occurs independently or in association with other disorders. Diagnosis of this nonspecific, benign inflammatory disease is a challenge to gastroenterologists, radiologists, surgeons and pathologists. CT features of the disease, usually highly suggestive, have recently been delineated clearly. Open biopsy seems rarely necessary. There is no standardized treatment, and it may consist of anti-inflammatory or immunosuppressive agents. We recommend resection only when the advanced inflammatory changes become irreversible or in cases of bowel obstruction. Overall prognosis is usually good and recurrence seems to be rare.

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REFERENCES 1 2

Zissin R, Metser U, Hain D, Even-Sapir E. Mesenteric panniculitis in oncologic patients: PET-CT findings. Br J Radiol 2006; 79: 37-43 Emory TS, Monihan JM, Carr NJ, Sobin LH. Sclerosing

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mesenteritis, mesenteric panniculitis and mesenteric lipodystrophy: a single entity? Am J Surg Pathol 1997; 21: 392-398 Vettoretto N, Diana DR, Poiatti R, Matteucci A, Chioda C, Giovanetti M. Occasional finding of mesenteric lipodystrophy during laparoscopy: a difficult diagnosis. World J Gastroenterol 2007; 13: 5394-5396 Grieser C, Denecke T, Langrehr J, Hamm B, Hanninen EL. Sclerosing Mesenteritis as a Rare Cause of Upper Abdominal Pain and Digestive Disorders. Acta Radiol 2008; 1-3 Gu GL, Wang SL, Wei XM, Ren L, Li DC, Zou FX. Sclerosing mesenteritis as a rare cause of abdominal pain and intraabdominal mass: a cases report and review of the literature. Cases J 2008; 1: 242 Delgado Plasencia L, Rodríguez Ballester L, LópezTomassetti Fernández EM, Hernández Morales A, Carrillo Pallarés A, Hernández Siverio N. [Mesenteric panniculitis: experience in our center] Rev Esp Enferm Dig 2007; 99: 291-297 Daskalogiannaki M, Voloudaki A, Prassopoulos P, Magkanas E, Stefanaki K, Apostolaki E, Gourtsoyiannis N. CT evaluation of mesenteric panniculitis: prevalence and associated diseases. AJR Am J Roentgenol 2000; 174: 427-431 Patel N, Saleeb SF, Teplick SK. General case of the day. Mesenteric panniculitis with extensive inflammatory involvement of the peritoneum and intraperitoneal structures. Radiographics 1999; 19: 1083-1085 Cuff R, Landercasper J, Schlack S. Sclerosing mesenteritis. Surgery 2001; 129: 509-510 McCrystal DJ, O'Loughlin BS, Samaratunga H. Mesenteric panniculitis: a mimic of malignancy. Aust N Z J Surg 1998; 68: 237-239 Shah AN, You CH. Mesenteric lipodystrophy presenting as an acute abdomen. South Med J 1982; 75: 1025-1026 Akram S, Pardi DS, Schaffner JA, Smyrk TC. Sclerosing mesenteritis: clinical features, treatment, and outcome in ninety-two patients. Clin Gastroenterol Hepatol 2007; 5: 589-596; quiz 523-524 Seo M, Okada M, Okina S, Ohdera K, Nakashima R, Sakisaka S. Mesenteric panniculitis of the colon with obstruction of the inferior mesenteric vein: report of a case. Dis Colon Rectum 2001; 44: 885-889 Ege G, Akman H, Cakiroglu G. Mesenteric panniculitis associated with abdominal tuberculous lymphadenitis: a case report and review of the literature. Br J Radiol 2002; 75: 378-380 Pickhardt PJ, Bhalla S. Unusual nonneoplastic peritoneal and subperitoneal conditions: CT findings. Radiographics 2005; 25: 719-730 Horton KM, Lawler LP, Fishman EK. CT findings in sclerosing mesenteritis (panniculitis): spectrum of disease. Radiographics 2003; 23: 1561-1567 Koornstra JJ, van Olffen GH, van Noort G. Retractile mesenteritis: to treat or not to treat. Hepatogastroenterology 1997; 44: 408-410 Parra-Davila E, McKenney MG, Sleeman D, Hartmann R, Rao RK, McKenney K, Compton RP. Mesenteric panniculitis: case report and literature review. Am Surg 1998; 64: 768-771 Mazure R, Fernandez Marty P, Niveloni S, Pedreira S, Vazquez H, Smecuol E, Kogan Z, Boerr L, Mauriño E, Bai JC. Successful treatment of retractile mesenteritis with oral progesterone. Gastroenterology 1998; 114: 1313-1317 Miyake H, Sano T, Kamiya J, Nagino M, Uesaka K, Yuasa N, Oda K, Nimura Y. Successful steroid therapy for postoperative mesenteric panniculitis. Surgery 2003; 133: 118-119 S- Editor Tian L L- Editor Kerr C

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