eMedicine Specialties > Gastroenterology > Intestine
Mesenteric Lymphadenitis: Treatment & Medication
Updated: Aug 5, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
The objective of medical management is to quickly identify patients who require surgical intervention (ie, for appendicitis) and to refer appropriately. Empiric, broad-spectrum antibiotics may be used in moderately to severely ill patients and should cover Yersinia strains, commonly causative in mesenteric adenitis. General supportive care includes hydration and pain medication after excluding acute surgical abdomen. Patients with mild, uncomplicated presentations do not require antibiotics, and supportive care generally suffices.
- Prehospital care
- Prompt transfer of patients to a facility where an appropriate workup can be conducted is the most important prehospital goal.
- Vascular access and saline infusion are beneficial for patients who are more ill and have volume depletion.
- Emergency department treatment
- Carefully evaluate patients to exclude potentially life-threatening alternative diagnoses.
- Initiate appropriate workup. Consult with a general surgeon when indicated.
- Hospital admission
- Patients with volume depletion, significant electrolyte imbalance, and/or sepsis require hospital admission.
- In instances for which diagnosis is not clear, inpatient observation and further workup may be appropriate.
Surgical Care
- Surgery is usually indicated in suppuration and/or abscess, with signs of peritonitis, or if acute appendicitis cannot be excluded with certainty.
- At laparotomy, the diagnosis is generally clear. An appendectomy should be performed in view of the tendency for recurrence of lymphadenitis and the difficulty in differentiating adenitis from appendicitis.
Consultations
Make early contact with a general surgeon while evaluating the patient to exclude etiologies that require urgent surgery.
Diet
No particular diet is recommended. Temporary withholding of oral intake may be necessary while nausea and vomiting resolve and initially until a definitive diagnosis is confirmed.
Activity
No restriction of activity is required.
Medication
Antibiotics are often started empirically in moderately to severely ill patients, using broad-spectrum antibiotics intended to cover the commonly associated pathogens. Antibiotic treatment should then be adjusted based on the sensitivity of the isolated pathogen. Treatment duration is variable based on the cause and severity of illness. For uncomplicated cases, antibiotic treatment is not necessary.
Antibiotics
When indicated, empiric antimicrobial therapy must be comprehensive and should cover the likely pathogens in the context of the clinical setting. Given the predominance of Y enterocolitica, initial antibiotic selection from trimethoprim-sulfamethoxazole (TMP-SMX), third-generation cephalosporins, fluoroquinolones, aminoglycosides, and doxycycline should be considered. These agents provide broad coverage for enteric pathogens.
Metronidazole (Flagyl, Protostat)
Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Exerts a bactericidal effect by inhibiting protein synthesis. Used in combination with other antimicrobial agents (except for Clostridium difficile enterocolitis).
Adult
Loading dose: 15 mg/kg or 1 g for 70-kg adult IV over 1 h
Maintenance dose (6h later): 7.5 mg/kg or 500-mg infusion for 70-kg adult IV over 1 h q6-8h; not to exceed 4 g/d
Pediatric
Administer as in adults, using body weight
Toxicity may be increased by cimetidine; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with orally ingested ethanol
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
Clindamycin (Cleocin)
Lincosamide used for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, thus causing cessation of RNA-dependent protein synthesis.
Adult
150-450 mg/dose PO q6-8h; not to exceed 1.8 g/d or 600-1200 mg/d IV/IM divided q6-8h, depending on degree of infection
Pediatric
8-20 mg/kg/d PO as hydrochloride and 8-25 mg/kg/d as palmitate divided tid/qid or 20-40 mg/kg/d IV/IM divided tid/qid
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity, regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
Ampicillin (Omnipen, Polycillin)
Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.
Adult
250-500 mg PO q6h
500 mg to 1.5 g IM q4-6h
500 mg to 3 g IV q4-6h; not to exceed 12 g/d
Pediatric
50-100 mg/kg/d PO divided q4-6h or 100-400 mg/kg/d IV/IM divided q4-6h
Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Amoxicillin (Amoxil, Trimox)
Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.
Adult
500 mg PO q8h; not to exceed 3 g/d
Pediatric
20-50 mg/kg/d PO divided q8h
Reduces the efficacy of oral contraceptives; aspirin and probenecid increase concentration
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Caution advised in patients with renal disease and seizure disorders
Ciprofloxacin (Cipro)
Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth. Trovafloxacin (Trovan) overcomes many of these limitations. Continue treatment for at least 2 d (7-14 d typical) after signs and symptoms have disappeared.
Adult
250-500 mg PO bid or 200-400 mg IV q12h
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Imipenem/cilastin (Primaxin)
For treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated because of potential for toxicity.
Adult
Base initial dose on severity of infection and administer in equally divided doses; dose may range from 250-500 mg IV q6h; not to exceed 3-4 g/d; alternatively, 500-750 mg IM (or intra-abdominally) q12h
Pediatric
<12 years: Not established; 15-25 mg/kg/dose IV q6h suggested for > 3 mo
Fully susceptible organisms: 15-25 mg/kg/dose IV q6h suggested for > 3 mo; not to exceed 2 g/d
Moderately susceptible organisms: 15-25 mg/kg/dose IV q6h suggested for > 3 mo; not to exceed 4 g/d
Coadministration with cyclosporine may increase adverse CNS effects of both agents; coadministration with ganciclovir may result in generalized seizures
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal insufficiency; avoid use in children <12 years
Cefoxitin (Mefoxin)
Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections. Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefoxitin.
Adult
1-2 g IV q6-8h; in severe infections 1-2 g IV q4h
Pediatric
Infants and children: 80-160 mg/kg/d IV divided q4-6h; higher doses for severe or serious infections; not to exceed 12 g/d
Probenecid may increase effects of; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis
Ticarcillin/clavulanate (Timentin)
Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth. Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positive bacteria, most gram-negative bacteria, and most anaerobes.
Adult
3.1 g IV q4-6h; infuse over 30 min
Pediatric
75 mg/kg IV q6h
Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels
Documented hypersensitivity; do not treat severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis with oral penicillin during acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis and BUN/creatinine determinations during therapy, and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
Ampicillin/sulbactam (Unasyn)
Drug combination of beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.
Adult
1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Pediatric
<3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adult; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
More on Mesenteric Lymphadenitis |
| Overview: Mesenteric Lymphadenitis |
| Differential Diagnoses & Workup: Mesenteric Lymphadenitis |
 Treatment & Medication: Mesenteric Lymphadenitis |
| Follow-up: Mesenteric Lymphadenitis |
| References |
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References
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Further Reading
Keywords
mesenteric lymphadenitis, mesenteric adenitis, mesenteric lymph nodes, intestinal lymphatics, Yersinia enterocolitica infection, peripheral lymphadenopathy, infectious Epstein-Barr virus, EBV, acute human immunodeficiency virus, HIV, catscratch disease, CSD, acute appendicitis
