MESENTERIC LYMPHADENITIS



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Mesenteric lymphadenitis is an inflammation of the lymph nodes on the wall of the mesentery (the covering of the intestines).

If is often a childhood illness, though occasionally seen in adults.

It is a very common cause of abdominal pain in children, mimicking appendicitis, and often difficult to differentiate from appendicitis.

It is estimated that 1 in 5 children diagnosed with appendicitis actually have mesenteric lymphadenitis.


Causes


Mesenteric lymphadenitis usually follow viral infection with the common cold, or with infection by Yersinia enterocolitica, Pseudo tuberculosis, Streptococcus viridansor Campylobacter jejuni.

While Streptococcus viridans, Campylobacterand Pseudo tuberculosis infection are common world wide, infection by Yersinia enterocolitica is mostly found in the cold regions of the world, especially in Europe and Australia.

The bugs gain access to the wall of the intestine, and invade the lymph nodes on the covering of the intestines called the mesentery.

The small intestine is frequently more involved, but the large intestines or colon may also be involved.

The lymph nodes become enlarged due to inflammatory process induced by the micro-organisms.

The inflammatory process, coupled with the stretch effect on the wall of the mesentery by the enlarged lymph node cause pain.

Pus may form in severe cases and spread to cause disseminated infection.

Most times though, the infection resolves on it own without the need to do anything.


Signs and Symptoms


The signs and symptoms of mesenteric lymphadenitis are very similar to those caused by appendicitis. They can however be differentiated from those of appendicitis by some subtle differences.

The child is usually not as unwell as one will expect in appendicitis, though in early appendicitis, children may look rather well even though they are symptomatic.

The main signs and symptoms include :


  • Abdominal Pain. This is often located in the right lower abdomen or right iliac fossa. It is a colicky abdominal pain which just resolves momentarily without any intervention. The sufferer, usually a child, may be completely pain free between attacks. Characteristically, the pain moves from one spot to the other on the abdomen, in keeping with the movement of the bowel loops in the abdominal cavity.

    Asking the child to turn to the left side will demonstrate this shift as the area of pain and tenderness will move along with the bowel to the left.

    In appendicitis, the pain may initially start around the umbilicus, then moves over to the right iliac fossa. Once it settles there, it does not move around any longer.


  • Preceding Cold or Sore Throat. One thing in the history that gives away the diagnosis of mesenteric lymphadenitis is that of the presence of common cold or sore throat in the days or week before the onset of abdominal pain. There may even still be an on going cough and cold in the child. The neck glands, if examines may still be swollen.


  • Fever. There may be an associated fever, running up to 38.5 degrees centigrade.

  • Vomiting. Patient may vomit. If they vomited before the onset of pain, appendicitis is most unlikely.


  • Diarrhoea. There may be episodes of loose stools, especially where Yersinia infection is involved. Appendicitis could also cause diarrhoea.


  • Anorexia. Usually, with mesenteric lymphadenitis, patients are still able to eat and drink. If a patient complains of abdominal pain, and appetite remains good, it is most unlikely he or she has appendicitis.

The following are a list of other causes of abdominal pain that may be more life threatening, but mimics mesenteric lymphadenitis.


Diagnosis


Diagnosis of mesenteric lymphadenitis is made from the history and examination.

Where strong doubt exists about the diagnosis, some laboratory and radiological investigations can be done. These include:


  • Full blood Count. This may show evidence of infection, with elevated white blood cells. It can not differentiate between appendicitis, mesenteric lymphadenitis, or any other infection.


  • Yersinia enterocolitica Serology. A positive serology will support the diagnosis of mesenteric adenitis.


  • Barium Enema. This is a very unlikely option in a child with abdominal pain. If done however, it may show indentation of the bowel walls from pressure by the enlarged mesenteric lymph nodes.


  • Ultrasound Scan. This may demonstrate hypoechoic nodules, which will be quite different from the surrounding tissues. Mesenteric thickening will also support a diagnosis of mesenteritis. This is often the first preferred investigation in children, since it is non –invasive, and there is no exposure to radiation (X-rays).


  • CT Scan. If done because the cause of abdominal pain remains unclear, in mesenteric adenitis, contrast CT will demonstrate enlarged mesenteric lymph nodes, plus a normal appendix.


  • Laparoscopy. If the diagnosis is still in doubt, a laparoscopy may lay it to rest. At laparoscopy, the lymph nodes surrounding the terminal ileum and colon may be found to be more in number and enlarged, with swelling of the mesentery, and a normal looking appendix.


Treatment


Mesenteric lymphadenitis is often a benign illness, which usually resolves on it own without treatment.

Observing the child over night for a day may be needed in the hospital if parents are seriously worried.

Symptoms like fever may need administration of medications like paracetamol; vomiting if severe, may need oral rehydration or intravenous fluid administration.

Some times, mesenteric lymphadenitis infection may become severe, requiring the administration of antibiotics or even outright surgical operation to remove a section of diseased bowel plus the appendix.



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