|
|
|
| Year : 1980 | Volume
: 26
| Issue : 4 | Page : 269-72 |
|
Sclerosing (retractile) mesenteritis.
SD Deodhar, RP Usgaoncar
Correspondence Address:
S D Deodhar
How to cite this article:
Deodhar S D, Usgaoncar R P. Sclerosing (retractile) mesenteritis. J Postgrad Med 1980;26:269-72
|
How to cite this URL:
Deodhar S D, Usgaoncar R P. Sclerosing (retractile) mesenteritis. J Postgrad Med [serial online] 1980 [cited 2023 Jun 10 ];26:269-72
Available from: https://www.jpgmonline.com/text.asp?1980/26/4/269/941 |
Full Text
INTRODUCTION
Intestinal obstruction is one of the commonest problems faced by a surgeon. Intestinal tuberculosis and malignancy are the two common causes of intramural obstruction in our country.
However, we recently came across a case at the K.E.M. Hospital, Bombay, of a benign condition that is rarely described in surgical text books and which at the time of operation may mimic malignancy. The rarity of this condition prompted us to report this case of sclerosing mesenteritis resulting in intestinal obstruction; this is a condition of inflammatory mesenteric scarring of an undetermined etiology.
CASE REPORT
A 70 year old male patient was admitted on 9-5-1979 to the K.E.M. Hospital, Bombay, with complaints of generalised colicky abdominal pain and absolute constipation for two days. He had abdominal distension but did not have vomiting. His past history did not show any significant features.
On examination, there was abdominal distension with visible loops of bowel around the umbilicus and occasional peristaltic waves. There was no guarding or tenderness. Liver and spleen were not palpable. There was no palpable lump elsewhere in the abdomen. Peristaltic sounds were exaggerated. Rectal examination did not reveal anything abnormal. The temperature, pulse and respiration were well maintained and there were no signs of dehydration. Laboratory investigations were not contributory.
A plain X-ray of the abdomen with the patient in the erect position showed multiple gas-fluid levels with distension of small bowel loops and absence of colonic gas.
With a clinical diagnosis of subacute intestinal obstruction, the patient was treated with nasogastric decompression, and intravenous alimentation. Enemata administered on two occasions resulted in passage of small amounts of flatus. As his condition did not improve satisfactorily, an exploratory laparotomy was performed under intratracheal gas-oxygen anaesthesia.
At exploration, there was a sector-like involvement of the mesentery, about 30 cm from the ileocaecal junction ending in a stricturous segment of bowel about 1.5 cm long [Fig. 1]. This was composed of firm, fibrous tissue encompassing the circumference of the bowel with distension oŁ proximal loops. The lumen of the bowel seemed markedly narrowed. Similar fibrous nodules extended to the root of the mesentery. It could not be ascertained whether these masses were lymph nodes or not. There was minimal peritoneal effusion, serous in nature.
Since the masses were extending to the root of the mesentery and entrapping the large vessels, resection was not attempted. A side to side anastomosis was performed to bypass the obstruction. One of the mesenteric nodules was excised for biopsy. It was not possible to remove the nodule intact as is done in a mesenteric node biopsy.
The post-operative recovery was uneventful and when last seen (one month after operation), the patient was asymptomatic and abdominal examination did not reveal anything abnormal.
Histopathological examination of the nodule showed dense collagenous fibrosis with mild focal lymphocytic and mononuclear cell infiltration of the mesentery [Fig. 2]. Occasional foci of dense collections of lymphomononuclear cells were also present. No granuloma or tumour was seen. Masson's trichrome stain confirmed the presence of dense collagenous tissue.
DISCUSSION
Jura,[7] in 1924, introduced the term "retractile mesenteritis" to describe a "condition of the mesentery associated with scarring and dislocation of intestinal loops." Different terms are used to describe this condition since then.[6], [8], [9]
There is a spectrum ranging from predominant fibrosis at one end to a dominance of lipogranuloma formation at the other. Reske and Namiki[8] call these two groups as Group A and Group B respectively, the former being seen at a comparatively younger age (mean-39.9 years) and the later being seen at a later stage (mean age-55.8 years).
Pathogenesis
Besically, the disease is supposed to be an expression of different stages of a reparative process in the mesentery in response to a non-specific injury. de Sanctis[5] hypothesized an allergic injury of the Schwartzman type to allergens absorbed from the gastro-intestinal tracts. Others[4], [8] postulate a response to irritation from leakage of bile, chyle, urine or intestinal contents. Other factors incriminated are blunt trauma, operative trauma, phlebitis, vasculitis, abnormal fat cell metabolism and thermal and chemical trauma.[8] Various infections and autoimmune diseases have also been blamed as causative agents.[8] The disease has been experimentally produced by intraperitoneal infection of E. coli and M. tuberculosis and by surgical trauma to the mesentery.
Symptomatology
The symptoms are non-specific and include episodic abdominal pain, distension, constipation, nausea, low grade fever and a palpable abdominal lump.[1], [4], [8]
Pathology
Most authors describe cicatrical, puckered lesions with nodule formation in the mesentery.[1], [2], [4], [6],[8],[9],[10]
Involvement of other structures like mesocolon, retroperitoneum, greater omentum and broad ligaments have also been described.[2], [8] The serosal surface of the bowel may show fibrotic plaques.[2] Firm greyish masses with areas of fatty necrosis and cyst formation and myxoid areas have also been described.[2] Regional nodes may be enlarged.[8] The associated adhesions and kinking of the bowel lead to intestinal obstruction. Infiltration of the intestinal muscles is infrequent[2] Aach et all and Black et ale have shown invagination of the bowel wall by the nodules. Usually blood vessels are closed in the fibrous tissue without vascular damage but sclerosis and thrombosis may rarely occur.[4], [8]
Diagnosis
Diagnosis is often made only at laparotomy. Laboratory investigations are not of diagnostic significance. Certain radiological features have been described as suggestive of the disease.[3], [10] Final diagnosis is however, only on histopathological examination.
Management
Laparotomy is indicated to confirm the diagnosis and to relieve the co-existing intestinal obstruction. Subsequently resection of the affected segment with restoration of intestinal continuity may be needed.[1], [8], [10] Jura7 claimed that exploratory laparotomy by itself may suffice to limit the progress of the disease. Steroids and radiation therapy have been tried but without much success.[1], [8] Only one fatal case has been reported so far.[8]
ACKNOWLEDGEMENT
Thanks are due to Dr. C. K. Deshpande, M.D., F.R.C. Path. (London), Dean, K.E.M. Hospital and Seth G.S. Medical College, Bombay, for permission to use the hospital records. Thanks are due to Dr. V. V. Joshi, M.D., M.R.C.P., Ph.D., for the histopathological report and photomicrographs: Thanks are also due to the members of the resident and nursing staff for help in the management of this patient.
|
