Clinical Case Summary

Sclerosing mesenteritis is an uncommon, benign mixed inflammatory and fibrotic condition of unknown etiology that affects the adipose tissue of the mesentery. Abdominal pain, nausea, vomiting, diarrhea, loss of appetite, and fever are just a few of the gastrointestinal and systemic symptoms that can be brought on by sclerosing mesenteritis. Although making a diagnosis is frequently difficult, however it can be done by maintaining a high index of suspicion based on the clinical presentation and ruling out other causes.
Here, we describe the case of a 56-years old gentleman with uncontrolled diabetes mellitus and hypertension who was referred to gastroenterology clinic from the emergency department after he presented there with postprandial epigastric abdominal pain for 5 days associated with nausea and early satiety. He denied hematemesis, melena, altered bowel habits and fever. He denied taking any medications. Examination was unremarkable except for generalized abdominal tenderness to palpation. Investigations showed elevated WBC, CRP and ALP 279 IU/L. CT abdomen and pelvis with contrast demonstrated mild fatty stranding in the root of the mesentery on the left side around the mesenteric vessels with low attenuation around it suggesting fat ring sign. Few prominent lymph nodes were seen in the mesentery, two small hypodense benign looking lesions were seen in the liver. Patient was diagnosed with sclerosing mesenteritis and started on prednisolone 30mg with slow taper as well as Calcium-Vitamin D supplements. Patient was asymptomatic after a month and three months of follow-up.
Our case highlights the importance of having a low threshold for the diagnosis of common presentation of an uncommon GI disorder. Sclerosing mesenteritis is a rare clinical condition with a delayed course of progression. Establishing diagnosis on clinical basis can be challenging for gastroenterologists.

References

Danford, Christopher J.; LIN, Steven C.; WOLF, Jacqueline L. Sclerosing mesenteritis. Official journal of the American College of Gastroenterology| ACG, 2019, 114.6: 867-873.‏
Wagner, Christopher; achmann, Abraham; Ehrenpreis, Eli D. Mesenteric Panniculitis, Sclerosing Mesenteritis and Mesenteric Lipodystrophy: Descriptive Review of a Rare Condition. Clinics in colon and rectal surgery, 2022, 35.04: 342-348.‏
Sulbaran, Marianny, et al. A Clinical Review of Mesenteric Panniculitis. Gastroenterology & Hepatology, 2023, 19.4: 211.‏

Introduction

Oesophageal adenocarcinoma (EAC) remains a leading cause of cancer-related mortality, with poor survival outcomes. Early identification and treatment of dysplasia in Barrett’s oesophagus (BE) is critical to reducing the risk of post-endoscopy upper gastrointestinal cancers (PEUGIC). While mucosal cleansing and clear visualisation are recognised as essential, existing evidence also demonstrates that certain procedural factors—such as longer inspection times—can significantly improve dysplasia detection rates (DDR) (2). This raises the possibility that other procedural variables may similarly influence detection outcomes. In this audit, we evaluated whether additional technical and patient-related factors affect dysplasia detection, with the aim of optimising surveillance quality and reducing the risk of Post-Endoscopy Upper GI Cancer (PEUGIC).

Aims & Methods

This audit aimed to assess the impact of procedural variables on dysplasia detection during Barrett’s surveillance endoscopy. A retrospective analysis was conducted in Wales, reviewing 192 patient records from June to December 2023. Factors that may influence dysplasia detection were evaluated including sedation type, use of acetic acid for mucosal enhancement, adherence to the Prague grading system, describing lesions using the Paris classification, NBI use and the Seattle biopsy protocol. Additionally, patient comfort was assessed as it may impact procedural quality and compliance. Analysis was carried out using SPSS (IBM, USA). T-tests were used for parametric data, and Mann Whitney U-tests for non-parametric data. Categorical data were analysed using Chi-square or Fisher’s exact tests. Statistical significance was set at p < 0.01.

Results

Improved imaging quality was significantly associated with higher patient comfort (p = 0.001). Higher doses of midazolam were associated with greater detection of visible lesions, while fentanyl showed less of a significant effect. Additional use of acetic acid and aceto-whitening effect significantly enhanced dysplasia detection, with strong alignment to histological findings (p<0.001). NBI further improved lesion identification when used adjunctively. In procedures performed by expert endoscopists, targeted biopsies identified dysplasia at comparable rates to the Seattle protocol, suggesting limited additional value of the latter in experienced hands.

Conclusion

This study underscores the importance of optimising procedural elements—particularly higher doses midazolam (median 5mg), acetic acid application, and ensuring patient comfort—to improve dysplasia detection in Barrett’s surveillance. Although PEUGIC data seems to show better neoplasia detection rates with combined Midazolam and Fentanyl, we did not demonstrate this(1). seattle protocol may still be helpful for dysplasia detection, but it’s use appears less beneficial than regular use of NBI and acetic acid chromoendoscopy.

References

1. Dhar A. Re: “Dedicated service for Barrett’s oesophagus surveillance endoscopy yields higher dysplasia detection and guideline adherence in a non tertiary setting in the UK: a 5-year comparative cohort study” by Ratcliffe et al. Frontline gastroenterology [Internet]. 2023 Mar;15(3):264. Available from: https://pubmed.ncbi.nlm.nih.gov/38665792/
2. Gupta N, Gaddam S, Wani SB, Bansal A, Rastogi A, Sharma P. Longer inspection time is associated with increased detection of high-grade dysplasia and esophageal adenocarcinoma in Barrett’s esophagus. Gastrointestinal Endoscopy. 2012 Sep;76(3):531–8

Introduction

The development of peroral endoscopic myotomy (POEM) has led to a paradigm shift in the treatment of esophageal motility disorders^1-5. Hiatal hernia (HH) has been reported in approximately 4-20% of patients with achalasia^6-8. Due to the altered position of the proximal stomach entering thoracic cavity, careful anatomical inspection at the completion of myotomy is essential to minimize the risk of adverse events⁷. Although two observational studies suggested that the presence of HH did not significantly affect clinical outcomes^9-10, these studies were limited by small sample sizes from single centers, with 13 and 56 cases of HH, respectively. Further study involving larger cohorts is needed to enable meaningful comparisons and to elucidate the impact of HH on POEM outcomes.

Aims & Methods

We hypothesized that the coexistence of a HH may be associated with adverse events, such as mediastinitis and esophageal perforation, or incomplete myotomy due to the technical challenges of approaching the esophagogastric junction^6-7. This retrospective cohort study aimed to compare outcomes between patients with and without HH undergoing POEM. Using the Nationwide Inpatient Sample in the United States from 2016 through 2022, we identified 6572 patients undergoing POEM for achalasia or non-achalasia spastic disorders. One-to-one propensity score matching was performed to compare adverse events, defined as any adverse event associated with an extended length of stay (>3 days), reintervention, 30-day mortality, and length of stay between the groups.

Results

Conclusion

The risk of adverse events and reintervention were higher in the HH group. These findings highlight the need for tailored management in POEM for HH cases.

References

[1] Inoue H, et al. POEM for esophageal achalasia. Endoscopy. 2010;42:265-71.
[2] Ramchandani M, et al. Recent Advancements and Future Perspectives of POEM. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2024;22:1983-96.e2.
[3] Inoue H, et al. Statement for GERD after POEM from an international multicenter experience. Esophagus. 2020;17:3-10.
[4] Ponds FA, et al. Effect of POEM vs Pneumatic Dilation on Symptom Severity and Treatment Outcomes Among Treatment-Naive Patients With Achalasia: A Randomized Clinical Trial. Jama. 2019;322:134-44.
[5] Inoue H, et al. Clinical practice guidelines for POEM. Digestive endoscopy. 2018;30:563-79.
[6] Ushimaru Y, et al. Occult Hiatal Hernia in Achalasia Patients: Its Incidence and Treatment Options. Dig Surg. 2019;36:418-25.
[7] Fletcher PR. Acute hiatal hernia with oesophageal perforation following Heller's operation. Br J Surg. 1978;65:486-8.
[8] Sanei-Moghaddam A, et al. Cricopharyngeal myotomy for cricopharyngeus stricture in an inclusion body myositis patient with hiatus hernia: a learning experience. BMJ case reports. 2013;2013.
[9] Xu P, et al. Peroral endoscopic myotomy is an effective treatment for achalasia combined with hiatal hernia. Surgical endoscopy. 2024;38:4543-9.
[10] Tutuian G, et al. Achalasia and Hiatal Hernia: A Rare Association and a Therapeutic Challenge. J Neurogastroenterol Motil. 2023;29:455-9.

Disclosure

No disclosures for this study