eMedicine Specialties > Radiology > Pediatrics

Mesenteric Adenitis

Author: Brian Burke, MD, Assistant Professor, Department of Radiology, University of New York School of Medicine; Consulting Radiologist, Department of Radiology, North Shore University Hospital
Coauthor(s): Micha Ziprkowski, MD, Associate Chief, Pediatric Radiology, Associate Professor of Clinical Radiology, Department of Radiology, North Shore University Hospital
Contributor Information and Disclosures

Updated: Mar 18, 2008

Introduction

Background

Mesenteric adenitis is a self-limited inflammatory process that affects the mesenteric lymph nodes in the right lower quadrant. Its clinical presentation mimics that of acute appendicitis. Until recently, the diagnosis was most frequently made when laparotomy performed to assess presumed appendicitis yielded negative findings; now, cross-sectional imaging is routinely applied in the examination of patients.

Pathophysiology

Mesenteric adenitis is most frequently caused by viral pathogens, but other infectious agents have been implicated, including Yersinia enterocolitica, Helicobacter jejuni, Campylobacter jejuni, and Salmonella or Shigella species.1,2,3 An association with streptococcal infections of the upper respiratory tract, particularly the pharynx, has been reported. In younger children and infants, concurrent ileocolitis may be present; this finding suggests that the lymph node involvement may occur in reaction to a primary enteric pathogen.

Related eMedicine topics:
Yersinia Enterocolitica Infection
Salmonella Infection

Related Medscape topics:
Helical CT Evaluation of Acute Right Lower Quadrant Pain: Part I, Common Mimics of Appendicitis
CME  The Step-Up Approach (Slides With Transcript)

Frequency

United States

In 2 recent series involving patients with clinical symptoms suggestive of acute appendicitis, mesenteric adenitis was the most frequent alternative diagnosis; it was present in 8-12% of patients. In Europe and North America, the proportion of patients with Y enterocolitica infection who undergo appendectomy is 3.0-9.0%.

International

As an etiologic agent of mesenteric adenitis, Y enterocolitica is less common in developing nations than in other nations. In Europe and North America, the proportion of patients with Y enterocolitica infection who undergo appendectomy is 3.0-9.0%. In 2 small studies of children who underwent appendectomy in Bangladesh, Yersinia organisms were not found.

Mortality/Morbidity

Most cases are self-limited, although disease lasting longer than 2 weeks is common. With Yersinia ileocolitis, small-bowel disease may be severe, and gangrene and death have been reported. Children who undergo laparotomy for presumed appendicitis are at risk for surgical complications.

Race

No racial predilection is reported.

Sex

Two large published series provide no information about the sex ratio. The clinical differential diagnosis in patients with right lower quadrant pain is broader in girls, especially in adolescents in whom gynecologic pathology must be considered.

Age

Mesenteric adenitis can occur in adults, but it is most common in children and adolescents younger than 15 years. Associated enteric disease most often occurs in those younger than 5 years.4

Anatomy

Mesenteric lymph nodes are present near mesenteric vessels and between bowel loops. They normally appear flattened, ovoid, or disc-shaped, and they have a characteristic fatty central hilum and a solid peripheral cortex (see Image 1). Vessels enter and exit the node at the hilum and branch within the node in a fashion similar to that of the kidney. Normal mesenteric lymph nodes vary in size, but, in general, the short-axis diameter is 4 mm or shorter.

Presentation

Mesenteric adenitis is a self-limited condition characterized by fever, abdominal pain, nausea, and, occasionally, diarrhea. Pain and tenderness are often centered in the right lower quadrant, but they may be more diffuse than in appendicitis. The site of tenderness may shift when the patient's position changes, whereas the location of the tenderness tends to be fixed with appendicitis. Leukocytosis is common.

The diagnosis of mesenteric adenitis is one of exclusion; confirmation is based on a benign clinical course, and management is conservative.

Preferred Examination

Ultrasonography of the right lower quadrant with graded compression has been the mainstay of diagnosis in children.5 Recently, many centers have adopted CT as an alternate or, sometimes, the primary diagnostic modality in the setting of presumed appendicitis, especially in men and in those in whom visualization of the appendix may be compromised by their body habitus. Although the findings are frequently nonspecific, abdominal radiographs occasionally reveal findings and permit alternative diagnoses (eg, appendicoliths).

Limitations of Techniques

The normal appendix is sonographically occult in a significant subset of patients. When lymph node enlargement is detected on sonographic examination in these patients, excluding appendicitis as a cause of reactive adenopathy is difficult.6,7

In some centers, CT is performed for the evaluation of appendicitis without intravenous and/or oral contrast enhancement. This approach reduces the sensitivity of CT for bowel wall thickening and mesenteric adenopathy, especially in small children with a paucity of intraperitoneal fat.

With any imaging modality, the finding of lymph node enlargement as an isolated finding is nonspecific; it can be observed in association with several inflammatory processes. Occasionally, nodes exceeding the normal size threshold are observed in children who have no demonstrable disease.

Differential Diagnoses

Appendicitis
Crohn Disease
Sprue

Other Problems to Be Considered

Infectious gastroenteritis
Lymphoma

More on Mesenteric Adenitis

Overview: Mesenteric Adenitis
Imaging: Mesenteric Adenitis
Follow-up: Mesenteric Adenitis
Multimedia: Mesenteric Adenitis
References

References

  1. Black RE, Slome S. Yersinia enterocolitica. Infect Dis Clin North Am. Sep 1988;2(3):625-41. [Medline].

  2. Hervas JA, Alberti P, Bregante JI, et al. Chronic intussusception associated with Yersinia enterocolitica mesenteric adenitis. J Pediatr Surg. Dec 1992;27(12):1591-2. [Medline].

  3. Garcia-Corbeira P, Ramos JM, Aguado JM, Soriano F. Six cases in which mesenteric lymphadenitis due to non-typhi Salmonella caused an appendicitis-like syndrome. Clin Infect Dis. Jul 1995;21(1):231-2. [Medline].

  4. Blattner RJ. Acute mesenteric lymphadenitis. J Pediatr. Mar 1969;74(3):479-81. [Medline].

  5. Hayden CK Jr. Ultrasonography of the acute pediatric abdomen. Radiol Clin North Am. Jul 1996;34(4):791-806. [Medline].

  6. Quillin SP, Siegel MJ. Appendicitis in children: color Doppler sonography. Radiology. Sep 1992;184(3):745-7. [Medline].

  7. Schulte B, Beyer D, Kaiser C, et al. Ultrasonography in suspected acute appendicitis in childhood-report of 1285 cases. Eur J Ultrasound. Dec 1998;8(3):177-82. [Medline].

  8. Borgia G, Ciampi R, Nappa S, et al. Tuberculous mesenteric lymphadenitis clinically presenting as abdominal mass: CT and sonographic findings. J Clin Ultrasound. Sep 1985;13(7):491-3. [Medline].

  9. Rao PM, Rhea JT, Novelline RA. CT diagnosis of mesenteric adenitis. Radiology. Jan 1997;202(1):145-9. [Medline].

  10. Simonovsky N, Hiller N. Importance of sonographic detection of enlarged abdominal lymph nodes in children. J Ultrasound Med. 2007;26(5):581-4. [Medline].

  11. Wiersma F, Toorenvliet BR, Ruige M, Holscher HC. Increased echogenicity of renal cortex: a transient feature in acutely ill children. AJR Am J Roentgenol. Jan 2008;190(1):240-3. [Medline].

  12. Puylaert JB. Mesenteric adenitis and acute terminal ileitis: US evaluation using graded compression. Radiology. Dec 1986;161(3):691-5. [Medline].

  13. Simonovsky V. Ultrasound in the differential diagnosis of appendicitis. Clin Radiol. Nov 1995;50(11):768-73. [Medline].

  14. Puylaert JB, van der Zant FM. Mesenteric lymphadenitis or appendicitis?. AJR Am J Roentgenol. Aug 1995;165(2):490. [Medline].

  15. Al-Kawas FH, Murgo A, Foshag L, Shiels W. Lymphadenopathy in celiac disease: not always a sign of lymphoma. Am J Gastroenterol. Mar 1988;83(3):301-3. [Medline].

  16. Achong DM, Oates E, Harris B. Mesenteric lymphadenitis depicted by indium 111-labeled white blood cell imaging. J Pediatr Surg. Dec 1993;28(12):1550-2. [Medline].

  17. Zganjer M, Roic G, Cizmic A, Pajic A. Infectious ileocecitis--appendicitis mimicking syndrome. Bratisl Lek Listy. 2005;106(6-7):201-2. [Medline].

  18. Zippi M, Colaiacomo MC, Marcheggiano A, et al. Mesenteric adenitis caused by Yersinia pseudotubercolosis in a patient subsequently diagnosed with Crohn's disease of the terminal ileum. World J Gastroenterol. Jun 28 2006;12(24):3933-5. [Medline].

Further Reading

Keywords

mesenteric lymphadenitis, acute ileitis, appendicitis, lymphoma

Contributor Information and Disclosures

Author

Brian Burke, MD, Assistant Professor, Department of Radiology, University of New York School of Medicine; Consulting Radiologist, Department of Radiology, North Shore University Hospital
Brian Burke, MD is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Coauthor(s)

Micha Ziprkowski, MD, Associate Chief, Pediatric Radiology, Associate Professor of Clinical Radiology, Department of Radiology, North Shore University Hospital
Micha Ziprkowski, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Radiology, American Institute of Ultrasound in Medicine, Association of University Radiologists, Radiological Society of North America, and Society for Pediatric Radiology
Disclosure: Nothing to disclose.

Medical Editor

Henrique M Lederman, MD, PhD, Consulting Staff, Department of Radiology, The Children's Hospital of Philadelphia; Professor of Radiology and Pediatric Radiology, Chief, Division of Diagnostic Imaging in Pediatrics, Federal University of Sao Paulo, Brazil
Henrique M Lederman, MD, PhD is a member of the following medical societies: Society for Pediatric Radiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

David A Stringer, BSc, MBBS, FRCR, FRCPC, Professor, National University of Singapore; Head, Diagnostic Imaging, KK Women's and Children's Hospital, Singapore
David A Stringer, BSc, MBBS, FRCR, FRCPC is a member of the following medical societies: British Columbia Medical Association, Canadian Association of Radiologists, European Society of Paediatric Radiology, Ontario Medical Association, Radiological Society of North America, Royal College of Physicians and Surgeons of Canada, Royal College of Radiologists, and Society for Pediatric Radiology
Disclosure: None None None

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

John Karani, MBBS, FRCR, Consulting Staff, Department of Radiology, King's College Hospital, London
Disclosure: Nothing to disclose.

 
 
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