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200 E. D. Ehrenpreis
Fig. 22.3 This additional coronal image in the same patient with mesenteric adenitis
demonstrates a normal caliber appendix that is partially filled with gas and oral contrast (arrow).
Images courtesy of Dr. Abraham Dachman and Dr. Justin Ramirez
have not been completely ruled out. Primary mesenteric adenitis is a self-limited
condition with a 1 to 7-day recovery period.
Surgical
Mesenteric adenitis does not require surgical management. When the appendix is
visualized and normal appearing using appropriate imaging, the diagnosis of acute
appendicitis is essentially ruled out. Under this circumstance, the patient may be
managed as a case of mesenteric adenitis. Expedited appendectomy is performed
when acute appendicitis is the most certain diagnosis results in better patient
outcomes.
22 Mesenteric Adenitis 201
Suggested Reading
1. Helbling R, Conficconi E, Wyttenbach M, et al. Acute nonspecific mesenteric lymphadenitis:
more than no need for surgery . Biomed Res Int. 2017;2017:9784565. https://doi.org/10.1155/
2017/9784565.
2. Patel NB, Wenzke DR. Evaluating the patient with right lower quadrant pain. Radiol Clin
North Am. 2015;53(6):1159–70.
3. Natrajan K, Medisetty M, Gawali R, et al. Strongyloidosis hyperinfection syndrome in an
hiv-infected patient: a rare manifestation of immune reconstitution inflammatory syndrome.
Case Rep Infect Diseases 2018, Article ID 6870768, 4 p, https://doi.org/ https://doi.org/10.
1155/2018/6870768.
4. Takada T, Nishiwaki H, Yamamoto Y, et al. The role of digital rectal examination for diagnosis
of acute appendicitis: a systematic review and meta-analysis. PLoS One. 2015;10(9):e0136996.
Published 2015 Sep 2. doi:https://doi.org/10.1371/journal.pone.0136996
5. Putrus AS, Piper MH. Mesenteric lymphadenitis. Medscape. https://emedicine.medscape.com/
article/181162-overview#a7
6. Macari M, Hines J, Balthazar E, Megibow A. Mesenteric adenitis. Am J Roentgenol. 2002;178
(4):853–8.
7. Mostbeck G, Adam EJ, Nielsen MB, et al. How to diagnose acute appendicitis: ultrasound first.
Insights Imaging. 2016;7(2):255–63.
8. Balthazar EA, Birnbaum BY, Yee J, MegibowAJ, Roshkow J, Gray C. Acute appendicitis: CT
and US correlation in 100 patients. Radiology 1994;190 31–35
9. Gorter RR, Eker HH, Gorter-Stam MA, et al. Diagnosis and management of acute appendicitis.
In: EAES consensus development conference 2015. Surg Endosc. 2016;30(11):4668–4690.
Mesenteric Abscess
Ryan T. Hoff and Eli D. Ehrenpreis
Definition
A mesenteric abscess is organized infection occurring within the mesenteric organ
(peritoneal connective tissue that attaches the stomach, small intestine, pancreas,
and splee n to the abdominal wall). While abdominal abscesses may occur in any
location within the abdominal cavity, mesenteric abscesses are confined to the
mesenteric connective tissue.
Pathophysiology
Several physiologic mechanisms work to limit infections within the peritoneum and
mesentery. The integrity of the lining of the gastrointestinal tract serves as an initial
anatomic barrier, while secretory immunoglobulin A prevents pathogens from
adhering to the intestinal wall. Once translocation occurs, the majority of bacterial
organisms are removed via lymphatic drainage. Lymphatic blockage can occur as a
consequence of infections such as cellulitis and filariasis, deep vein thrombosis,
neoplasm and radiation injury. Damage and obstruction may result in the development of infections and associated inflammation. Neutrophil infiltration enhances
local inflammation. This in turn promotes increased blood flow by dilation of local
vasculature.
As this suppurative inflammation continues, liquefactive necrosis occurs and
then forms an abscess. A mass of necrotic cells develops in the center, while an
outer margin of intact cells persists. The abscess may organize further and become
walled off as fibrin is deposited at the margins. The formation of an abscess helps to
23
R. T. Hoff E. D. Ehrenpreis (&)
Department of Medicine, Advocate Lutheran General Hospital, 1775 Dempster St, 6 South, Park
Ridge, IL 60068, USA
e-mail: e2bioconsultants@gmail.com
© Springer Nature Switzerland AG 2021
E. D. Ehrenpreis et al. (eds.), The Mesenteric Organ in Health and Disease,
https://doi.org/10.1007/978-3-030-71963-0_23
203
204 R. T. Hoff and E. D. Ehrenpreis
contain the extent of the infection, while the mesentery provides a means of
anatomically compartmentalizing the potential spaces of the peritoneum, thereby
limiting the spread of infection.
Any factors that promote bacterial translocation, including inflamm atory bowel
disease, surgery, or trauma, increase the risk for developing a mesenteric abscess. In
addition, any host factors that impair immune function, including malignancy,
immunosuppressive therapies, malignancy, or diabetes mellitus may also incre ase
the risk of abscess formation. Increased age and malnutrition are additional risk
factors.
Epidemiology
The overall incidence of mesenteric abscess has not been reported. The vast
majority of mesenteric abscess occur secondary to an underlying disorder, injury, or
insult that compromises the integrity of the intestinal mucosa. Primary mesenteric
abscesses, i.e. abscesses that occur in the absence of any provoking event or
underlying condition, are exceptionally rare. Secondary causes of mesenteric
abscess include diverticulitis, appendicitis, Crohn’s disease, malignancy, and
trauma (Table 23.1). Small intestinal diverticula may become complicated by
diverticulitis and perforation, leading to mesenteric abscesses. A Meckel's diverticulum may become occluded from enteroliths, parasites, malignancy, or peptic
ulcer related fibrosis. Such an obstruction may lead to Meckel's diverticulitis, with
perforation and mesenteric abscess formation. Severe peptic ulcer disease may
become complicated by perforation, leading to mesenteric abscess formation.
A mesenteric abscess may occur as a postoperative complication of abdominal or
pelvic surgeries, such as open radical hysterectomy. A mesenteric abscess as the
presenting finding of carcinoma has been reported. Conditions causing immunodeficiency, such as HIV/AIDS, increase the risk of opportunistic infections,
including mycobacterium avium complex and mycobacterium tuberculosis, which
may cause mesenteric abscesses. In immunosuppressed patients, Yersinia enterocolitica infection of the terminal ileum may spread to lymph nodes, leading to
abscess formation. Infection with Enterobius vermicularis, also known as pinworm,
has been reported to cause mesenteric abscess, with a presentation similar to perforated appendicitis.
Crohn’s disease is of particular relevance to mesenteric abscess formation.
Inflammatory disease increases the risk of infection by compromising bowel wall
integrity, allowing penetration by bacteria to extraintestinal sites. Immunosuppressive agents and surgery also increase the overal l infection risk. Postoperative
abdominal abscess occurs as a complication of peritoneal exposure to bacteria
during the operation, or secondary to anastomotic leakage. Tobacco use increases
the risk of both abscesses and fistulas in Crohn’s disease. Corticosteroids are also
known to increase the of intra-abdominal abscess in Crohn’s disease. Azathioprine
increases the risk of postoperative intra-abdominal infectious complications in
23 Mesenteric Abscess 205
Table 23.1 Causes of mesenteric abscesses
Iatrogenic Post-operative complication
Immune suppression AIDS/HIV related infections
Solid organ transplant recipients
Immunomodulating medications
Chemotherapy
Infectious Enterobius vermicularis (Pinworm)
Mycobacterium avium complex
Mycobacterium tuberculosis
Yersinia enterocolitica
Enterobius vermicularis (Pinworm)
Malignancy Carcinoma
Perforation, Leading to Abscess Appendicitis
Ileal diverticulitis
Jejunal diverticulitis
Meckel’s diverticulum
Collagen disorders, Ehlers Danlos Syndrome
Peptic ulcer
Trauma
Primary Idiopathic
Crohn’s disease. However, azathioprine do es not appear to increase the risk of
intra-abdominal infection in non-operative Crohn’ s disease. Vedolizumab, administered before or after surgery, does not app ear to increase the risk of the risk of
post-operative abscesses in Crohn’s disease, although there may be an increased
risk of surgical site infections in patients treated with vedolizumab preoperatively.
In patients with Crohn’s disease with an intra-abdominal abscess, ongoing treatment with a tumor necrosis factor alpha (TNF) antagonist is currently considered to
be safe. Ustekinumab does not increase the risk of post-operative infection when
compared with anti-TNF agents.
Symptoms
The presentation of mesenteric abscess varies by location and clinical context.
Symptoms may include fever, chills, sweats, and abdominal pain. Much of the
symptomatology is determined by the location involved. Perigastric abscesses may
cause early satiety, nausea and vomiting. Large abscesses of the small intestine may
cause a small bowel obstruction, leading to nausea, crampy abdominal pain, and
inability to pass flatus or stool. Perirectal abscesses may cause tenesmus.
206 R. T. Hoff and E. D. Ehrenpreis
Physical Findings
Exam findings for mesenteric abscess may include fever, tachycardia, and a palpable abdominal mass. The abdominal mass may be freely mobile, easily shifted
from side to side via palpation. If there is underlying Crohn’s disease, a perianal or
enterocutaneous fistula may be present. Additional systemic manifestations of
infection are often present, such as tachycardia and diaphoresis. In the setting of
bowel obstruction, abdominal distension may be observed. Mesenteric abscesses
may rupture, leading to peritoneal signs, with guarding and rebound tenderness.
Laboratory Testing
Laboratory results are nonspecific and represent the presence of underlying bacterial infection. Findings may include leukocytosis, bandemia, elevated inflammatory markers (erythrocyte sedimentation rate and C reactive protein), and
procalcitonin. Blood cultures may be positive for a single organism, or multiple
pathogenic bacteria. Culture of drained purulent material, acquired via radiologic
guidance or surgery, is the gold standard for microbiologic diagnosis. Infectious
organisms may include gram negative rods such as Escherichia coli, anaerobic
bacteria such as Bacteroides fragilis and Peptostreptococcus species, or gram
positive cocci including staph aureus, streptococcus, and Enterococcus species.
Tuberculosis may be isolated in rare cases. When possible, a microbiologic diagnosis should be obtained, which also may provide sensitivities to antimicrobial
therapy. In most cases, abscesses are polymicrobial. In the setting of immunosuppression, staining with acid fast bacilli should be considered to detect mycobacterial infection.
Diagnosis and Imaging
Computerized tomography (CT) of the abdomen and pelvis is the imaging test of
choice in most cases of suspected mesenteric abscess. Images demonstrate a well
circumscribed mass containing fluid and surrounding inflammatory changes
(Fig. 23.1), which may contain pockets of air. Additional findings may include
thickening of the intestinal wall, intestinal dilation with air fluid levels, and enlarged
mesenteric lymph nodes. If intravenous contrast is used, the mass may be ring
enhancing.
Ultrasound provides the benefit of avoiding radiation but offers more limited
anatomic information. Plain film radiography may demonstrate evidence of
intra-abdominal abscess but is significantly less sensitive and specific than CT
imaging.
23 Mesenteric Abscess 207
Fig. 23.1 Crohn’s abscess. Round, well-circumscribed fluid collection in the lower abdomen with
surrounding inflammatory changes compatible with a mesenteric abscess in this patient with a
prior diagnosis of Crohn’s disease (arrow)
Barium enema may demonstrate the presence of an intra-abdominal mass, with
bowel loop separation or displacement. In one series of patients with Crohn’s
disease, these findings on barium enema (suggesting a mass) indicated a mesenteric
abscess in one third of cases. The most common finding in these cases was the
presence of fibrofatty changes of the mesentery.
The presence of a mesenteric abscess observed on imaging should prompt
investigation regarding the likely etiology of this finding. Potential etiologies include Crohn’s disease and complicated jejunoileal diverticulitis. Additi onal diagnostic considerations include malignancy, foreign body related perforations,
traumatic hematomas, and medication induced ulcers. Depending on anatomic
location, the initial presentation of mesenteric abscess can be identical to acute
appendicitis. Complicated Meckel’s diverticular perforation should be considered,
particularly if gastrointestinal bleeding is present or if exploratory laparotomy is
performed which shows a normal appearing appendix. In women, the presentation
can be similar to ectopic pregnancy, pelvic inflammatory disease, tubo-ovarian
abscess, and hemorrhagic or ruptured ovarian cysts.
Treatment
In most cases, definitive therapy requires drainage of the abscess. Drainage may be
achieved either percutaneously with CT guidance or by a surgical technique.
Antibiotics should be administered, with a regimen directed at treating the most
likely causative organisms.
208 R. T. Hoff and E. D. Ehrenpreis
If complicated ileal or jejunal diverticulitis is suspected, surgery should be
pursued. Surgery may be laparoscopic or open and consists of resection of diseased
bowel followed by primary anastomosis. Percutaneous abscess drainage and
antibiotics may be considered in select patients with Ehlers Danlos Syndrome, as
these patients presents challenges in achieving successful surgical outcomes,
including poor wound healing, enterocutaneous fistula formation, and bleeding.
There is increasing interest in the use endoscopic techniques for drainage of
mesenteric abscesses. Endoscopic ultrasound guided drainage may be effective for
postoperative mesenteric abscesses.
Small mesenteric abscesses in Crohn's disease (less than 3 cm) may be treated
with antibiotics alone; this often leads to resolution. Abscesses greater than 3 cm in
patients with Crohn’s disease may benefit from percutaneous drainage. Percutaneous drainage and antibiotics are effective for the majority of Crohn’s disease
related abscesses. In the minority of cases that require surgery, percutaneous
drainage in advance may allow for sufficient healing that a primary anastomosis is
feasible at the time of operation, thus avoiding a multistep surgery with a diverting
ostomy.
Surgery is indicated if medical therapy and percutaneous drainage is unsuccessful or additional abnormalities, such as congenital malrotation or fistula are
present. Risk factors that predict the need for surgery in patients with Crohn’s
disease include large multifocal and multiloculated abscesses, the presence of
colonic disease, and concomitant corticosteroid therapy. Amongst patients requiring
ileocecal or ileocolic resections for Crohn's disease, the presence of an abscess is a
risk factor for anastomotic-associated complications. Surgery for Crohn's-related
abscesses consists of exploration and evacuation of the abscess, irrigation and
debridement of the abscess cavity. Resection of diseased bowel is usually necessary; however, excessive resection should be avoided to minimize the risk of short
bowel syndrome. Patients with an abscess in the setting of refractory pancolitis or
fistula formation may require a complete proctocolectomy with end ileostomy.
Additional surgi cal options for severe disease include segmental colectomy and
subtotal colectomy with ileorectal anastomosis; the choice of surgery depends
largely on the clinical context and the extent of disease.
Suggested Reading
1. Hokama A, et al. Mesenteric abscess in Crohn's disease. Gastrointest Endosc. 2005;62(2):306;
discussion 306.
2. Navarro C. Perforated diverticulum of the terminal ileum. A previously unreported cause of
suppurative pylephlebitis and multiple hepatic abscesses. Dig Dis Sci. 1984;29(2):171–7.
3. Sakpal SV, Fried K, Chamberlain RS. Jejunal diverticulitis: a rare case of severe peritonitis.
Case Rep Gastroenterol. 2010;4(3):492–7.
4. Seitun S, et al. Perforated Meckel’s diverticulitis on the mesenteric side: MDCT findings.
Abdom Imaging. 2012;37(2):288–91.
5. Ko EM. Robotic versus open radical hysterectomy: a comparative study at a single institution.
Gynecol Oncol. 2008;111(3):425–30 Epub 2008 Oct 16.
23 Mesenteric Abscess 209
6. Yamagata Y, et al. Poorly differentiated mesenteric carcinoma of unknown primary site
detected by abscess formation: case report. World J Surg Oncol. 2014;8(12):4.
7. Luo Y, et al. Primary mesenteric adenocarcinoma covered by abscess of the mesocolon and
intestinal obstruction: a case report. Mol Clin Oncol. 2017;6(4):593–6 Epub 2017 Feb 13.
8. Watanabe K, et al. Mesenteric lymph node abscess due to Yersinia enterocolitica: case report
and review of the literature. Clin J Gastroenterol. 2014;7(1):41–7 Epub 2014 Jan 9.
9. Mohar SM, et al. Small bowel obstruction due to mesenteric abscess caused by
Mycobacterium avium complex in an HIV patient: a case report and literature review.
J Surg Case Rep. 2017;2017(7):rjx129. eCollection 2017 Jul.
10. Beeson BB, Woodruff AW. Mesenteric abscess caused by threadworm infection. Trans R Soc
Trop Med Hyg. 1971;65(4):433.
11. Agrawal A, et al. Effect of systemic corticosteroid therapy on risk for intra-abdominal or
pelvic abscess in non-operated Crohn’s disease. Clin Gastroenterol Hepatol. 2005;3
(12):1215–20.
12. Law CCY, et al. Systematic review and meta-analysis: preoperative vedolizumab treatment
and postoperative complications in patients with inflammatory bowel disease. J Crohns
Colitis. 2018;12(5):538 – 45.
13. Lightner AL, et al. Postoperative outcomes in vedolizumab-treated patients undergoing
abdominal operations for inflammatory bowel disease. J Crohns Colitis. 2017;11(2):185–90
Epub 2016 Aug 19.
14. Ibáñez-Samaniego L, et al. Safety and efficacy of Anti-TNFa treatment in Crohn’s disease
patients with abdominal abscesses. Hepatogastroenterology. 2015;62(139):647–52.
15. Lightner AL, et al. Postoperative outcomes in Ustekinumab-treated patients undergoing
abdominal operations for Crohn’s disease. J Crohns Colitis. 2018;12(4):402–7.
16. Cheung HY, et al. Acute abdomen: an unusual case of ruptured tuberculous mesenteric
abscess. Surg Infect (Larchmt). 2005;6(2):259–61.
17. Casey MC, et al. Non-operative management of diverticular perforation in a patient with
suspected Ehlers-Danlos syndrome. Int J Surg Case Rep. 2014;5(3):135–7 Epub 2014 Jan 8.
18. Strong S, et al. Clinical practice guideline for the surgical management of Crohn’s Disease.
Dis Colon Rectum. 2015;58(11):1021–36.
19. Raza A, et al. Concomitant laparoscopic ileocolectomy and ladd’s procedure for Crohn’s
ileocolitis with mesenteric abscess and congenital megacolon. Am Surg. 2016;82(9):e284–6.
20. Feagins LA, et al. Current strategies in the management of intra-abdominal abscesses in
Crohn’s disease. Clin Gastroenterol Hepatol. 2011;9(10):842–50 Epub 2011 May 5.
Mesenteric Venous Thrombosis
Nyi Nyi Tun and Eli D. Ehrenpreis
Introduction
Mesenteric venous thrombosis (MVT) is the formation of a blood clot within the
mesenteric venous system, including the superior and inferior mesenteric veins or
their venous tributaries. The superior mesenteric vein is generally the site of
involvement of MVT. Thrombosis of the inferior mesenteric vein thrombosis is a
rare occurrence. The presentation of MVT may be acute, subacute or chronic, each
of these having different clinical patterns with possible overlap between the various
forms. MVT is one of the recognized causes of mesenteric ischemia which refers to
inadequate perfusion to meet the metabolic demands of visceral organs, (see
Chap. 26 Ischemic Enteropathy).
24
Epidemiology
MVT may present with symptoms including abdominal pain or may be an
asymptomatic incidental finding on abdominal imaging. Despite va riation in the
literature, MVT is estimated to account for 5–15% of cases of acute mesenteric
ischemia. Compared to acute MVT, cases of chronic MVT are reported less frequently, likely because of vague or absent symptoms in a large number of these
patients. MVT is the primary diagnosis for 1 in 5,000 to 15,000 hospital admissions
and approximately 0.1% of emergency surgical laparotomies for acute abdomen.
N. N. Tun
Department of Internal Medicine, Miami Valley Hospital, Dayton, OH 45409, USA
e-mail: drtun85@gmail.com
E. D. Ehrenpreis (&)
Department of Medicine, Advocate Lutheran General Hospital, 1775 Dempster St, 6 South,
Park Ridge, IL 60068, USA
e-mail: e2bioconsultants@gmail.com
© Springer Nature Switzerland AG 2021
E. D. Ehrenpreis et al. (eds.), The Mesenteric Organ in Health and Disease,
https://doi.org/10.1007/978-3-030-71963-0_24
211