Mesenteric lymphadenitis, also known as mesenteric adenitis, refers to nonspecific self-limiting inflammation of the mesenteric lymph nodes. It is considered present if a cluster of three or more lymph nodes, each measuring 5 mm or greater, is detected in the right lower quadrant mesentery. This condition is more likely to affect children under 16 years than adults.
Understanding Mesenteric Lymphadenitis
Lymphadenitis is a condition in which the small round or bean-shaped clusters of cells, called lymph nodes, become swollen and inflamed. The swelling can affect the lymph nodes in the membrane that connects the bowel to the wall around the stomach area, called the mesentery.
The mesentery attaches the intestine to the abdominal wall and holds it in place. Lymph nodes, or glands, are part of the lymphatic system and occur throughout the body. As part of the immune system, lymph nodes help to protect the body against infection and disease. They store lymphocytes, which are white blood cells that fight infections.
When infection occurs, the number of white blood cells increases and the lymph glands swell and become painful. The lymph nodes that are closest to the infection will be the most affected. If the lymph glands of the mesentery react to an infection in the abdomen or the intestine, they will swell and become painful, causing abdominal discomfort.
Causes of Mesenteric Lymphadenitis
Mesenteric adenitis usually results from a viral or bacterial infection. In such cases, mesenteric lymphadenitis also presents secondary to bacterial or viral gastroenteritis. The pathophysiology for such infection to occur takes place as follows: The bacteria/virus is ingested orally and able to enter the body's bloodstream via invasion through the intestinal epithelium. The organism then localizes to the nodal lymph tissue of the body surrounding intestinal mucosa; this commonly occurs in Peyer's patches. From there, the organism can spread regionally through lymphatic pathways to mesenteric lymph nodes resulting in mesenteric adenitis.
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It may also occur with some kinds of cancer or inflammatory bowel disease (IBD). Sometimes doctors can't tell the cause of mesenteric lymphadenitis. But the most common cause is infection, such as a viral or bacterial stomach bug. Inflammatory conditions may also be linked with mesenteric lymphadenitis.
Infections that cause mesenteric lymphadenitis may be located in one place (local) or throughout the body (systemic). The infections may be caused by viruses, bacteria, or parasites.
Common infections that cause mesenteric lymphadenitis include:
- Gastroenteritis: This may result from viral infections such as rotavirus or norovirus. It may also result from bacterial infections such as E. coli, Salmonella, Staphylococcus, or Streptococcus. Gastroenteritis is often misnamed stomach flu.
- Yersinia enterocolitica: This is the most common cause of mesenteric lymphadenitis in children. This bacteria, found in undercooked meat, can cause gastroenteritis and other problems. It may resemble Crohn's disease or acute appendicitis.
- Other infections: Direct or indirect infections related to HIV, tuberculosis, acute terminal ileitis.
Inflammatory conditions commonly linked to mesenteric lymphadenitis are:
- Appendicitis, inflammation of the appendix
- Inflammatory bowel diseases such as Crohn's disease or ulcerative colitis
- Connective tissue diseases such as lupus, sclerosis, or rheumatoid arthritis
- Diverticulitis, inflammation of the lining of the large intestine
- Pancreatitis, inflammation of the pancreas, are less common causes.
The etiologies of mesenteric adenitis include several causes of inflammatory response within mesenteric lymph nodes. These include viral infections, bacterial infections, inflammatory bowel disease, or lymphoma. Two common gram-negative bacteria that are known to cause mesenteric adenitis include Yersinia pseudotuberculosis and Yersinia enterocolitica. Other known culprits include Salmonella, E. coli, and Streptococci. The etiology can further classify as primary versus secondary. Primary etiology occurs when the lymphadenopathy is the result of an unidentifiable inflammatory process. Secondary mesenteric adenitis occurs secondary to an intra-abdominal inflammatory process with a known source or etiology.
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Primary mesenteric adenitis is most commonly lymphadenopathy in the mesentery near the terminal ileum without a discoverable underlying cause for the inflammation.
Fecal-oral transmission occurs in Y. enterocolitica infection and may present as a common source outbreak. This infection has also been associated with meat, milk, and water contamination. Mesenteric lymphadenitis has been a reported finding in approximately a third of patients with multisystem inflammatory syndrome in children (MIS-C), a rare delayed, postinfectious complication of COVID-19.
Epidemiology
The true incidence of this disease is not known because it can be easily missed or mistaken for other diagnoses. The condition is generally thought to be common. Frequency is similar to that of the United States. Yersinia enterocolitica infection has a geographic variation. The condition affects males and females equally. Mesenteric lymphadenitis can occur in adults but is more common in children and adolescents younger than 15 years, and this condition during childhood or adolescence is linked to a significantly reduced risk of ulcerative colitis in adulthood.
Histopathology
The lymphoid tissue of mesenteric adenitis, when examined under a microscope, will show an increased density of plasma cells and immunoblasts in the cortical and paracortical regions, capsular edema and thickening, lymphocyte accumulation within dilated sinuses, and hyperplasia of germinal centers.
Symptoms of Mesenteric Lymphadenitis
With mesenteric lymphadenitis, an upper respiratory tract infection may occur right before any other symptoms appear. This may cause symptoms such as a sore throat. Symptoms of mesenteric lymphadenitis range in severity.
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Symptoms of mesenteric adenitis are similar to those of appendicitis, but the condition is not as serious.
Symptoms include:
- Stomach pain
- Fever
- Diarrhea
- Nausea and vomiting
Stomach pain may be localized near the belly button, to the lower, right side, or possibly widespread. Mesenteric lymphadenitis often causes symptoms in the lower right abdomen. It can be mistaken for appendicitis or intussusception, both conditions that require emergency medical attention. You may have other signs and symptoms as well. This depends upon the cause of the inflammation.
Other signs and symptoms include:
- Feeling ill
- Loss of appetite
- Fatigue or lack of energy
- Raised white blood cell count
Mesenteric adenitis most commonly presents in pediatric and young adult populations. A child under ten years of age who presents with acute onset right lower quadrant abdominal pain is more likely to have mesenteric adenitis rather than acute appendicitis. Mesenteric adenitis commonly follows recent gastroenteritis or upper respiratory infection. Common symptoms include fever, vomiting, change in bowel habits, periumbilical, and/or right lower quadrant abdominal pain. Many surgeons will note that pain from palpation during a physical exam is notably less in the presentation of mesenteric adenitis when compared to acute appendicitis.
When to Seek Medical Attention
In most cases, the problem will resolve without intervention. However, medical help should be sought if the pain gets worse, or any of the following occur:
- Sudden severe stomach pain
- Stomach pain with fever
- Stomach pain with diarrhea or vomiting
A person should also see a doctor if pain interferes with sleep, and if there is a change in appetite or in bowel habits that do not resolve on their own. Mesenteric adenitis is not normally dangerous, but having swollen lymph nodes for a long time can be a sign of something more serious. If the glands are swollen due to a severe bacterial infection, and it is not treated, it can spread to the bloodstream, and this can lead to sepsis. Sepsis is an infection of the blood and is life-threatening.
Symptoms of mesenteric adenitis can be confused with those of an ectopic pregnancy, as well as of appendicitis. If a woman has symptoms and she could be pregnant, she should seek medical help at once.
Call your doctor right away if you or your child has severe or sudden abdominal pain. Also call if it occurs along with other symptoms such as those listed above. Describe to your doctor the severity and location of the pain, as well as what makes it worse. Be prepared to discuss any other symptoms you or your child has had. Sometimes mesenteric lymphadenitis causes no symptoms. The doctor may simply spot it while doing imaging tests for some other problem.
Diagnosis of Mesenteric Lymphadenitis
Sometimes symptoms of mesenteric lymphadenitis may lead you to go to see a doctor. The doctor will ask about these symptoms and take a thorough medical history. They may also do some tests. Diagnosing mesenteric lymphadenitis involves taking a medical history and doing an exam.
A doctor can confirm a diagnosis of mesenteric adenitis by:
- Examining a person and looking at their medical history.
- Doing imaging studies, such as an abdominal ultrasound or a computerized tomography (CTG) scan of the abdomen, to see whether the person has mesenteric adenitis or appendicitis. A scan may show that the lymph nodes are enlarged, or that the wall of the intestine is thickened.
- Sending a blood sample for a laboratory test, to see if an infection is present, and if so, which type it is. A range of pathogens may be responsible.
Blood tests may help spot an infection. Urine tests may help rule out a urinary tract infection. An abdominal ultrasound or CT scan can help rule out other causes of symptoms. Many conditions are linked to mesenteric lymphadenitis -- some serious, others not. So you can see why a diagnosis is so important.
The clinician should obtain a complete blood count, C-reactive protein (CRP), and urine analysis. The WBC and CRP will generally be elevated, but the diagnosis cannot be ruled out even if they are within normal limits. The urinalysis is helpful to rule out a urinary tract infection. However, these laboratory studies will not help the clinician delineate between diagnoses of appendicitis, intussusception, or mesenteric adenitis.
Abdominal ultrasonography is the gold standard for the diagnosis of mesenteric adenitis. Ultrasound that shows enlarged, hypoechoic mesenteric lymph nodes and the absence of a thickened blind-ending tubular structure (inflamed appendix) is diagnostic of mesenteric adenitis. The current radiological definition defines mesenteric adenitis as at least one abnormally enlarged lymph node measuring 8 mm or more in its short-axis diameter. Lymph node enlargement can also present in acute appendicitis and perforated appendicitis, adding to the difficulty of correctly diagnosing the disease process; however, the lymph nodes tend to be less enlarged and numerous in cases of appendicitis.
Recently, the use of superb microvascular imaging Doppler ultrasound has been studied in the pediatric population for achieving a diagnosis of mesenteric lymphadenitis. This new technique of Doppler ultrasound has proven to show low-velocity blood flow with better image resolution when compared to color Doppler flow imaging. A recent retrospective study compared the use of superb microvascular imaging (SMI) in addition to ultrasound with ultrasound alone in the pediatric patient population diagnosed with mesenteric lymphadenitis. The authors demonstrated increased sensitivity, specificity, and accuracy with the addition of SMI to ultrasound compared to ultrasound alone, 81.5% v. 63%, 76.7% v. 66.7%, and 78.9% v. 64.9%, respectively.
Treatment and Management
Mesenteric lymphadenitis often gets better without treatment in 1-4 weeks. Mild cases of mesenteric lymphadenitis and those caused by a virus usually go away on their own. Still, you may need medicine to reduce a fever or control pain. Rest, fluids, and warm heat applied to the abdomen may also help relieve symptoms. You may need treatment for the cause of the inflammation.
The first step in management is to rule out the diagnoses, which require surgical intervention. After establishing the diagnosis of mesenteric adenitis, the treatment is as follows: supportive care with IV hydration and pain control with nonsteroidal anti-inflammatory medications.
For treatment of fever or pain, consider giving your child infants' or children's over-the-counter fever and pain medications such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin, others). Use caution when giving aspirin to children or teenagers. Though aspirin is approved for use in children older than age 3, children and teenagers recovering from chickenpox or flu-like symptoms should never take aspirin.
Additional self-care measures include:
- Get plenty of rest.
- Drink fluids.
- Apply moist heat.
- Eat a liquid diet in small amounts.
It is essential to explain the diagnosis clearly to the patient and family, as there is often no apparent cause; this can cause anxiety and concerns for patients and their families, so it is vital to warn them that improvement may take time and can happen slowly over several weeks. It is appropriate to schedule office visits during this window to monitor their progress and discuss concerns.
Natural Treatment Options
A range of pathogens may be responsible for mesenteric lymphadenitis. Natural treatment options that may support immune health and help to fight the infection include:
- Echinacea: A herb that is derived from the echinacea plant and is used to help fight infections. The herb can boost the immune system and remove the toxins that cause infection. This can help speed up the healing process.
- Wild indigo: This supplement is known for its infection-fighting properties, but it must be used with echinacea, or it may be toxic. Used correctly, it can cleanse the immune system and helps to fight disease.
- Licorice: Used to treat a variety of infections because it is anti-inflammatory and enhances mucosal protection. It can also help with mesenteric adenitis by loading the intestinal tract with healthy bacteria.
At present, there is little scientific evidence to support the use of these natural remedies, however.
Differential Diagnosis
The differential diagnosis includes appendicitis, intussusception, ovarian cyst rupture, ovarian abscess, ectopic pregnancy, endometriosis, ovarian torsion, testicular torsion, epididymitis, pelvic inflammatory disease, mesenteric ischemia, chronic abdominal pain, inflammatory bowel diseases such as Crohn's or ulcerative colitis, systemic lupus erythematous, malignancy, HIV, zoonotic infections, infectious mononucleosis, and tuberculosis.
Prognosis
Mesenteric lymphadenitis generally is a benign disease. Typically, complete recovery can be expected without specific treatment. The pain typically resolves within four weeks without sequelae. Again, patients/families should be instructed about the length of this recovery and may be followed in the clinic to monitor for the resolution of symptoms. In cases where the underlying pathogen is Y. enterocolitica, some patients may develop arthralgias. These symptoms typically develop 1 month after the initial episode of diarrhea and usually resolve after 1-6 months.
Complications
There are no complications associated with mesenteric adenitis as it resolves without intervention.
Prevention
Mesenteric adenitis is not always preventable, but the risk of bacterial and viral infections can sometimes be reduced.
Some things that people can do to reduce the risk of mesenteric adenitis include:
- Regular hand washing with soap and water. This can kill bacteria and viruses to avoid spreading them to other people.
- Avoiding a person who is sick. Some bacteria and viruses can be spread through close contact with others.
- Disinfection.
Pearls and Other Issues
These patients are oftentimes misdiagnosed with appendicitis and historically have undergone an unnecessary appendectomy. This misdiagnosis occurs less often nowadays, thanks to improved diagnostic imaging and better clinical understanding of the disease.
Enhancing Healthcare Team Outcomes
Achieving the correct diagnosis in these patients is vitally important and can help avoid unnecessary surgery. It is important to take a detailed history and physical exam and be vigilant when evaluating for possible appendicitis and confirm on diagnostic imaging whether or not the appendix is well visualized and if it appears abnormal. An incorrect diagnosis can lead to unnecessary invasive interventions to the patients with subsequent morbidities.
Preparing for an Appointment
If your child has symptoms of mesenteric lymphadenitis, make an appointment with a healthcare professional.
To prepare for the appointment, it's helpful to gather the following information:
- Your child's symptoms, including symptoms that don't affect the stomach, and when they began.
- Your child's key medical information, including other health conditions.
- A list of all medicines, vitamins, and supplements your child takes, including doses.
Questions to ask your doctor include:
- What's the likely cause of my child's condition?
- Does my child need treatment?
- What can I do to make my child more comfortable?
- How bad is the pain?
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