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Mesenteric Lymphadenitis

Lymphadenitides Mesenteric

Mesenteric lymphadenitis refers to the inflammation of the lymph nodes in the mesentery of the abdomen. It usually presents with colicky abdominal pain in the right iliac region, fever, diarrhea, and vomiting.


Presentation

Mesenteric lymphadenitis is usually mild and self-limiting. it is similar in clinical presentation to acute appendicitis; however, there are subtle distinguishing features including the significant morbidity or severity of symptoms associated with acute appendicitis.

The main clinical features of mesenteric lymphadenitis include abdominal pain which is colicky in nature and could resolve spontaneously. The pain may be generalized or localized in the right iliac region of the abdomen [5]. Typically, the pain is migratory, moving from one part of the abdomen to another in tandem with the gastrointestinal peristaltic waves. In contrast, the pain in appendicitis doesn't migrate any further after settling in the right iliac region from the peri-umbilical area.

Mesenteric lymphadenitis open link usually occurs after a history of colds or sore throat.

There may be associated high-grade fever, vomiting, malaise, diarrhea, and anorexia depending on the etiologic factor [6]. Vomiting occurring before the onset of the pain is strongly suggestive of acute appendicitis open link. Anorexia is more associated with acute appendicitis than mesenteric lymphadenitis.

On physical examination, there may be abdominal guarding and tenderness often localized to the right lower abdominal quadrant. The classic physical signs of acute appendicitis such as Rovsing's sign may be absent.

Hemophilia A
  • The first two patients survived but the last one subsequently died from underlying hemophilia A (GI bleeding). Acute mesenteric lymphadenitis can be one of the unusual manifestations caused by P. marneffei.[ncbi.nlm.nih.gov]
Fever
  • Therefore, mesenteric lymphadenitis should be considered in HIV-infected persons who present with prolonged fever and abdominal pain.[ncbi.nlm.nih.gov]
  • Its symptoms include fever, severe abdominal pain, nausea, and, in some cases, diarrhea, constipation, and acute abdomen.[ncbi.nlm.nih.gov]
  • The patient presented with fever, abdominal pain, and a palpable right abdominal mass. Abdominal ultrasonic imaging and computerized axial tomography (CT) revealed a mass.[ncbi.nlm.nih.gov]
  • This report describes how indium 111-labeled white blood cell imaging helped to clarify the confusing case of a 4-year-old boy with fever, pharyngitis, and abdominal pain.[ncbi.nlm.nih.gov]
  • A 38-year-old Indian woman presented with a six-week history of epigastric pain, low-grade fever and anorexia. Upper endoscopy showed a gastric ulcer of the posterior wall of the stomach.[ncbi.nlm.nih.gov]
Malaise
  • Other symptoms of the disease include fever, malaise, vomiting, diarrhea, and nausea. However, mesenteric lymphadenitis often presents with mild symptoms and resolves without treatment.[symptoma.com]
  • […] pathos, suffering] lymphadenopathy /lym·phad·e·nop·a·thy/ ( -op ah-the ) disease of the lymph nodes. angioimmunoblastic lymphadenopathy , angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) a systemic lymphoma-like disorder characterized by malaise[medical-dictionary.thefreedictionary.com]
  • Depending on what's causing the ailment, other signs and symptoms may include: Diarrhea, Nausea and vomiting, general feeling of being unwell (malaise). In some cases, swollen lymph nodes are found on imaging tests for another problem.[omicsonline.org]
  • […] centered on the lower, right side, but the pain can sometimes be more widespread General abdominal tenderness Fever Depending on what's causing the ailment, other signs and symptoms may include: Diarrhea Nausea and vomiting General feeling of being unwell (malaise[fortishealthcare.com]
  • […] lymphadenitis There is an abdominal tenderness and fever Abdominal pain can be felt on the center on the lower, right side, but sometimes the pain can spread to some parts of the body Experiencing nausea, vomiting and diarrhea A feeling of being unwell or malaise[basicfirstaid.ca]
Whipple Disease
  • Apart from these common infections, some other factors that may cause mesenteric lymphadenitis include: Whipple disease; systematic bacterial infection. Tuberculosis . Acute terminal ileitis. Infections related to HIV.[natural-health-news.com]
  • A bacterial infection known as Whipple disease An inflammation found at the end of the small intestine known as acute terminal ileitis and is caused by bacteria or Crohn’s disease.[basicfirstaid.ca]
  • Some of these infections include: gastroenteritis, Whipple disease, and Yersina enterocolitica; Y. enterocolitica is the second most common cause of mesenteric lymphadenitis in pediatric patients and the commonest cause in Eastern Europe.[symptoma.com]
Abdominal Pain
  • An acutely ill child with abdominal pain and concomitant pharyngitis often presents a diagnostic challenge.[ncbi.nlm.nih.gov]
  • Therefore, mesenteric lymphadenitis should be considered in HIV-infected persons who present with prolonged fever and abdominal pain.[ncbi.nlm.nih.gov]
  • In general, call your doctor right away if your child has episodes of: Sudden, severe abdominal pain Abdominal pain with fever Abdominal pain with diarrhea or vomiting In addition, call your doctor if your child has episodes of the following signs and[fortishealthcare.com]
  • Its symptoms include fever, severe abdominal pain, nausea, and, in some cases, diarrhea, constipation, and acute abdomen.[ncbi.nlm.nih.gov]
  • A 17-year-old girl who had right lower abdominal pain with multiple swelling of lymph nodes in the ileocecal region and she was admitted to a neighboring hospital.[ncbi.nlm.nih.gov]
Severe Abdominal Pain
  • Its symptoms include fever, severe abdominal pain, nausea, and, in some cases, diarrhea, constipation, and acute abdomen.[ncbi.nlm.nih.gov]
  • In general, call your doctor right away if your child has episodes of: Sudden, severe abdominal pain Abdominal pain with fever Abdominal pain with diarrhea or vomiting In addition, call your doctor if your child has episodes of the following signs and[fortishealthcare.com]
  • If the affected person or child has severe abdominal pain, vomiting and bloody diarrhea, there is a need to seek a medical help and these symptoms requires an overnight observation in a hospital.[basicfirstaid.ca]
Acute Abdomen
  • Clinicians should remember that cryptococcal infection of mesenteric lymph nodes may rarely mimic an acute abdomen and cause delay in diagnosis.[ncbi.nlm.nih.gov]
  • Its symptoms include fever, severe abdominal pain, nausea, and, in some cases, diarrhea, constipation, and acute abdomen.[ncbi.nlm.nih.gov]
  • The Radiology Assistant : Acute Abdomen - Role of Ultrasound www.radiologyassistant.nl/.../ acute-abdomen-role-of-ultrasound .html Acute Abdomen - Role of Ultrasound ...[bigconsumers.tk]
  • Mesenteric adenitis can mimic acute appendicitis, ovarian torsion, intussusception, and other causes of an acute abdomen.[ultrasoundconnection.com]
  • There are many illnesses which may mimic the symptoms and the signs of an "acute abdomen".[kundoc.com]
Food Poisoning
  • Diarrhea often is associated with gastroenteritis or food poisoning. Appendicitis should be suspected in any child with pain in the right lower quadrant.[aafp.org]
Right Lower Quadrant Tenderness
  • Physical examination revealed a flushed diaphoretic man, a non-distended abdomen with focal right lower quadrant tenderness. Rovsing’s was negative.[sisna.org]

Workup

Blood investigations are critical in the diagnosis of mesenteric lymphadenitis. These include complete blood count which may demonstrate leucocytosis with white blood counts exceeding 10,000/µL in more than half of the patients. Blood electrolytes are usually within normal ranges except in cases with severe vomiting in whom electrolyte analysis reveal azotemia and metabolic alkalosis.

Serology is necessary in the diagnosis of mesenteric adenitis caused by Yersinia enterocolica.

Urinalysis may be necessary to exclude urinary tract infection as a possible differential. Cultures of the stool, blood, and other body fluids may also be necessary in the evaluation of a patient with mesenteric lymphadenitis. Empirical treatment is changed to more appropriate antibiotics as determined by the results of the culture and sensitivities. 

Imaging studies may be necessary in evaluating patients with suspected mesenteric adenitis. Contrast computed tomography (CT) scans may reveal the enlarged lymph nodes with thickening of the ileal or ileocecal wall; this situation, however, may not be present [7]. The appendix usually appears normal. The lymph nodes are usually larger in size, and more numerous in mesenteric lymphadenitis. 

The diagnostic criteria for mesenteric lymphadenitis by CT scan, as noted by Rao et al, includes the presence of at least 3 lymph nodes with a short-axis diameter of at least 5 mm clustered in the right lower quadrant [7]. CT scanning is also necessary to exclude other intra-abdominal pathologies such as regional enteritis, lymphoma, and intussusception.

Doppler ultrasound is necessary to support the diagnosis of mesenteric lymphadenitis and exclude possible differentials [8] [9]. Ultrasonography is the initial imaging study preferred for children and adults with mild cases of mesenteric lymphadenitis. Ultrasonography could detect thickening of the mesentery with thickening of the wall of the terminal ileum.

Treatment

Medical care is aimed at excluding a case of surgical abdomen such as acute appendicitis. Once mesenteric lymphadenitis has been diagnosed, broad-spectrum antibiotics are administered empirically. Empirical antibiotics should cover Yersinia strains [10]. Empirical antibiotics are not indicated in mild, uncomplicated cases and are reserved for moderate to severe cases. Supportive care is also vital and includes fluid resuscitation and analgesia.

Surgery is indicated if there is abscess formation, suppuration, peritonitis, or if other causes of acute surgical abdomen cannot be definitely ruled out.

Prognosis

Mesenteric lymphadenitis is not associated with mortality or significant morbidity and patients are very responsive to treatment. However, certain complications including sepsis, abscess formation, and peritonitis may result and significantly increase the morbidity. Furthermore, patients who have developed any of these complications may be at a higher risk of mortality.

Frisch and other scientists in a review of many cohort and Danish studies involving 709,353 patients who had received treatment for mesenteric adenitis demonstrated that children and adolescents who developed mesenteric adenitis have a lowered risk of ulcerative colitis in adulthood [4].

Etiology

Mesenteric lymphadenitis can be caused by a number of conditions. However, the most common cause is infection. These infections may be local or systemic and may be viral, bacterial, or parasitic. Some of these infections include: gastroenteritis, Whipple disease, and Yersina enterocolitica; Y. enterocolitica is the second most common cause of mesenteric lymphadenitis in pediatric patients and the commonest cause in Eastern Europe [2]. Other infectious causes include HIV, cat-scratch diseasetuberculosis, and acute terminal ileitis [3].

Organisms implicated in the etiogenesis of mesenteric lymphadenitis include staphylococcus species, Escherichia coli, Streptococcus viridans, Campylobacter jejuni, Giardia lamblia, Epstein-Barr virus, Rubeola virus, Coxsackie A and B viruses and adenovirus

Mesenteric lymphadenitis may also be as a result of cancer, including pancreatic cancer, gastrointestinal tumors, lung cancer, breast cancer, and lymphoma.

Inflammatory conditions have also been linked to mesenteric lymphadenitis. The common causes include inflammatory bowel diseases such as ulcerative colitis and Crohn's disease, diverticulitis, pancreatitis, appendicitis, rheumatoid arthritis, systemic sclerosis, and systemic lupus erythematosus [4].

Some cases of mesenteric lymphadenitis are idiopathic.

Epidemiology

The true incidence of mesenteric lymphadenitis is not known, mainly because it is often underdiagnosed, being mistaken for a number of similar differentials especially acute appendicitis. Approximately 20% of patients who undergo appendectomy were observed to have mesenteric adenitis.

Mesenteric lymphadenitis is most commonly seen in the temperate regions of Europe and Australia.

Mesenteric lymphadenitis can occur at any age, however, it is most prevalent in children and adolescents who are younger than 15 years. Researchers have indicated that the occurrence of mesenteric lymphadenitis in childhood and adolescence significantly reduces the risk of ulcerative colitis in adulthood [4].

Sex distribution
Age distribution

Pathophysiology

Microbes gain entry from the infective foci or bloodstream to the mesenteric lymph nodes through the intestinal lymphatic vessels. The microbes multiply and invade the nodes producing different levels of inflammation, depending on the extent of virulence of the organism.

The inflamed lymph nodes appear enlarged and the mesentery becomes edematous with the presence or absence of exudates.

Histologically, nonspecific hyperplasia is seen in the lymph nodes and necrosis with extensive exudates is seen in suppurative infection.

Prevention

Home remedies and supportive care are helpful in hastening the resolution of symptoms in mild and uncomplicated cases of mesenteric lymphadenitis: adequate rest, adequate fluid intake, and application of heat on the site of the pain help in providing relief from symptoms. Fluid intake prevents dehydration from the fever, emesis, and diarrhea. Over-the counter pain medications may be necessary in mild cases.

Summary

Mesenteric lymphadenitis is also known as mesenteric adenitis. It refers to an inflammation of the lymph nodes in the abdominal mesentery. The inflammation could be acute or chronic, depending on the etiology.

Mesenteric lymphadenitis is caused by a number of diseases, most of which are infectious diseases of the gastrointestinal organs. The causative organisms range from bacteria, viruses to protozoa. HIV and tuberculosis are common causes of mesenteric lymphadenitis. It has also been noted to occur after or during an episode of upper respiratory tract infection. Yersinia enterolitica infections are the second commonest cause of mesenteric infections and the commonest causes in the countries in Eastern Europe.

Non-infectious causes of mesenteric adenitis include cancers of the gastrointestinal tract, lymphomas, and chronic inflammatory conditions such as inflammatory bowel diseases (Crohn disease and ulcerative colitis) and systemic lupus erythematosus.

Mesenteric lymphadenitis presents with colicky abdominal pain which may be generalized or localized to the right iliac region. This makes it somewhat indistinguishable from acute appendicitis [1]. Other symptoms include diarrhea, malaise, vomiting, nausea, and anorexia.

Diagnosis of mesenteric lymphadenitis involves blood work comprising of complete blood count (CBC) and blood cultures. Urinalysis, stool cultures are also necessary to determine the definite infective cause and exclude differential diagnoses. Imaging studies play a crucial role in the evaluation of patients with mesenteric lymphadenitis. CT scanning and ultrasonography are necessary to confirm the presence of the disease and exclude possible differential diagnoses.

Treatment of mesenteric lymphadenitis depends on the severity of the symptoms. However, antibiotics and supportive care is the mainstay of treatment. Surgery is indicated if diagnosis is inconclusive, an acute surgical abdomen is diagnosed, or surgical complications of mesenteric adenitis follow.

Patient Information

  • Overview

The mesentery is the thin layer of tissue that connects the intestines to the wall of the abdomen and holds the bowels in place. The lymph nodes are small pea-shaped structures where tissue fluid (lymph) and immune cells are formed. Inflammation of the lymph nodes in the mesentery is called mesenteric lymphadenitis.  It is also called mesenteric adenitis.

  • Etiology

Mesenteric lymphadenitis is the most commonly caused infections of the gut. These infections are caused by small microorganisms which are transmitted via ingesting contaminated food or water. Common infective causes of mesenteric lymphadenitis include bacterial gastroenteritis, HIV, and tuberculosis.

These organisms gain entry into the mesentery and the lymph nodes through some vessels called the lymphatic vessels and infect the nodes causing inflammatory changes.

Other causes of mesenteric lymphadenitis include cancers affecting the gut, lung cancer, breast cancer, and chronic inflammatory conditions including inflammatory bowel diseases, rheumatoid arthritis, and systemic lupus erythematosus (SLE).

  • Epidemiology

Mesenteric lymphadenitis is most commonly seen in eastern Europe and it is also very common in the temperate areas of North America and Australia. Although mesenteric lymphadenitis can occur at any age, it is most common among children and teenagers.

Researchers have posited that occurrence of mesenteric lymphadenitis in childhood reduces the risk of a certain inflammatory bowel disease called ulcerative colitis in the adulthood.

  • Presentation

Mesenteric lymphadenitis presents with a sudden pain which may be localized to the right side of the lower abdomen or may be widespread in the abdomen. This pain waxes and wanes and is similar to the pain caused by acute appendicitis, hence, these 2 conditions are often mistaken for each other. Other symptoms of the disease include fever, malaise, vomiting, diarrhea, and nausea. However, mesenteric lymphadenitis often presents with mild symptoms and resolves without treatment.

Mesenteric lymphadenitis is often confused with acute appendicitis and up to 20% of patients who have undergone surgical removal of the appendix actually had mesenteric lymphadenitis. One distinguishing feature between mesenteric lymphadenitis and acute appendicitis is that the vomiting precedes the abdominal pain in acute appendicitis.

  • Diagnosis

Diagnosis of this condition requires that your doctor asks certain questions about a preceding febrile illness. Physical examination which indicates pain and tenderness in the right side of the lower abdomen also suggests this diagnosis, however imaging studies such as an abdominal computed tomography (CT) and doppler ultrasound are necessary to confirm the diagnosis and rule out other life-threatening possibilities which may require urgent surgery such as acute appendicitis.

Other investigations include blood count, urine analysis, blood, stool, and urine cultures with sensitivities.

  • Treatment

Before treatment commences, other severe surgical causes of the symptoms or surgical complications of mesenteric lymphadenitis should be excluded. Once confirmed, treatment of mesenteric lymphadenitis may commence. Treatment involves antibiotics, intravenous fluids, and pain relief medications.

Antibiotics may not be necessary for those who have mild symptoms. For these patients, rest, adequate intake of fluid, and pain relievers are adequate to relieve the symptoms.

References

Article

  1. Sung T, Callahan MJ, Taylor GA. Clinical and imaging mimickers of acute appendicitis in the pediatric population. AJR Am J Roentgenol. 2006; 186 (1):67-74.
  2. Ellis H, Calne R, Watson C. Lecture Notes on General Surgery.Tenth edition. p.28. ISBN 0-632-06371-8.
  3. Macari M, Hines J, Balthazar E, et al. Mesenteric adenitis: CT diagnosis of primary versus secondary causes, incidence, and clinical significance in pediatric and adult patients.  AJR Am J Roentgenol. 2002;178(4):853-858.
  4. Frisch M, Pedersen BV, Andersson RE. Appendicitis, mesenteric lymphadenitis, and subsequent risk of ulcerative colitis: cohort studies in Sweden and Denmark. BMJ. 2009; 338: b716.
  5. Lucey BC, Stuhlfaut JW, Soto JA. Mesenteric lymph nodes seen at imaging: causes and significance. Radiographics. 2005; 25(2):351-365.
  6. Zissin R, Rathaus V, Gayer G, et al. CT findings in patients with familial Mediterranean fever during an acute abdominal attack. Br J Radiol. 2003; 76:22-25.
  7. Rao PM, Rhea JT, Novelline RA. CT diagnosis of mesenteric adenitis. Radiology. 1997; 202 (1): 145-149.
  8. Toorenvliet B, Vellekoop A, Bakker R, et al. Clinical differentiation between acute appendicitis and acute mesenteric lymphadenitis in children. Eur J Pediatr Surg. 2011; 21(2):120-123.
  9. Ackerman SJ, Irshad A, Anis M. Ultrasound for pelvic pain II: nongynecologic causes. Obstet Gynecol Clin North Am. 2011; 38(1):69-83, viii.
  10. El Braks R, Harnois F, Boutros N, et al. Mesenteric adenitis and portal vein thrombosis due to Fusobacterium nucleatum. Eur J Gastroenterol Hepatol. 2004;16(10):1063-1066.

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Last updated: 2018-06-21 22:44