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Abdominal Pain and Weight Loss

A58-year-old white female presented with an eight-month history of progressive lower abdominal pain and bloating. She experienced intermittent constipation followed by a five-month period of persistent loose, watery diarrhea, a 35-pound weight loss, fatigue, anorexia, and avoidance of food.

Her past medical and surgical history were significant for hypertension, depression, appendectomy, laparoscopic ovarian cystectomy (of benign histology), and cholelithiasis. Her medication list consisted of pindolol and sertraline. Her physical exam was remarkable for abdominal distention, palpable mass, fluid wave, shifting dullness, and hypoactive bowel sounds. There was no tenderness or organomegaly. She had a mild microcytic anemia with no leukocytosis. Liver chemistries and electrolytes were normal. The erythrocyte sedimentation rate was 51. The initial CT scan of the abdomen is shown at right. TH

The initial CT scan

The initial CT scan

What is the most likely differential diagnosis?

  1. Pneumatosis intestinalis;
  2. Ovarian carcinoma or peritoneal carcinomatosis;
  3. Sclerosing mesenteritis;
  4. Spontaneous bacterial peritonitis; or
  5. Lymphoma.

Discussion

The answer is C: sclerosing mesenteritis (SM). The CT scan shows a bulky heterogeneous mesenteric mass measuring approximately 8.7 x 6 x 10 cm, with a focal, 2-cm calcification at the lateral margin. The mass began at the proximal superior mesenteric artery, extended inferiorly to the top of the pelvis, and encased the body of the pancreas, central mesenteric vessels and the confluence of the portal, splenic, and superior mesenteric veins (SMV). The SMV was poorly visualized and may have been compressed or occluded by the mass. Diffuse abdominal and pelvic ascites also were seen.

Results of a needle biopsy of the mesenteric mass showed fibrous tissue and a mixed population of B cells and T cells consistent with sclerosing mesenteritis, a fibroinflammatory reactive process.

Historic Puzzler Answer: Jacques Cartier’s Diagnosis

The answer to June’s “Historic Puzzler #2”

By Jamie Newman, MD, FACP

In our second “Historic Puzzler” (June, p. 13) Jacques Cartier was faced with a dilemma. His men began to fall ill with a disease that attacked their skin and teeth, leading to fatigue, weakness, and death.

Cartier’s men were suffering from scurvy. Western medicine would have to wait until James Lind in 1754 authoritatively identified citrus fruits as the cure, though the Dutch had used lemon juice 200 years earlier. Scurvy rates were as high as 75% in the British Royal Navy. The “primitive” Iroquois Indians were well versed in this disease and advised Cartier and his crew to ingest boiled white cedar bark, which is rich in Vitamin C.

“Had they known what they were getting into, I suspect the Iroquois would have rethought their gesture,” says Eric Siegal, one of our 19 respondents who knew the correct answer.

Mike Hamilton, writing from Newmarket, Ontario, Canada, noted that the event occurred in the location of the present day Quebec City. Collin Kroen says the cedar cure was called “annedda.”

To summarize, we received 19 correct responses to “Historic Puzzler 2” from these contributors: Tim Kilkenny, Collin Kroen, John Powell, Deborah Anderson, Tom Rafalski, Bentley McEntire, Bijo Chacko, Randall Moseley, Matt Kolleck, Eric Siegal, Tom Herbert, Jerry Young, Juan Sollis, Isaac Opole, Alberto Burgos-Tiburcio, Mike Hamilton, Ion Dan Bucaloiu, Jim Pittard, and Dawn Breznia.

Like SHM, these respondents represent both academic and private practice across the United States and Canada who work in adult and pediatric hospital medicine. TH

Sclerosing or retractile mesenteritis is an uncommon, idiopathic, nonneoplastic, tumor-like lesion that thickens and shortens the mesentery.1 The condition consists of a pathophysiological spectrum of disease, the classification of which is based on the predominant histological finding on tissue biopsy. Cases in which the predominant findings are fatty degeneration and necrosis are known as the mesenteric lipodystrophy variant; those in which chronic inflammation predominates are known as the mesenteric panniculitis variant; and finally, the predominantly fibrotic form is known as the retractile mesenteritis or mesenteric fibrosis variant.

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Gastroenterology

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