CLINICAL PROFILE OF MESENTERIC LYMPHADENITIS IN CHILDREN
Sathish .K*, Paramesh.H**, Hemalatha .V***, Salim. A. Khatib****
Department of Pediatrics.*, Department of Pediatrics.**, Department of Pediatrics.***, Department of Pediatrics.****
Introduction
Mesenteric adenitis is a self-limiting 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 laparoscopy was performed to assess presumed appendicitis yielded negative findings. Presently cross-sectioned imaging is routinely applied in the examination of children to make a possible diagnosis.
Pathophysiology
Mesenteric adenitis is most frequently caused by viral pathogens, but other infective agents have been implicated, including Yersinia enterocolitica, Helicobacter jejuni, Campylobacter jejuni, and Salmonella or Shigella species. 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 be a reactive process to a primary enteric pathogen.
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. Vessels enter and exit the node at the hilum and branch within the node in a fashion similar to that of the kidney. The normal mesenteric lymph node vary in size, but, in general, the short-axis diameter is 4 mm or shorter.
Preferred Examination
Ultrasonography of the right lower quadrant with graded compression has been the mainstay of diagnosis in children. Recently, many centers have adopted CT as an alternate or, sometimes the primary diagnostics modality in the setting of presumed appendicitis.
Retrospective Study
From August 2005 to August 2006
Objective
Ultrasonic confirmation of clinically diagnosed mesenteric lymphadenitis and analysis of clinical spectrum.
Method
A retrospective study of 15 children, clinically diagnosed as mesenteric adenitis, confirmed by ultrasonic study; during the period august 05 to august 06, were evaluated. The clinical presentation was correlated with ultrasound and laboratory investigations.

Total Diagnosed Mesenteric Adenitis (By Ultrasound) Cases - 15



August 2005 to December 2005 - 6 cases
January 2006 to April 2006 - 9 cases
May 2006 to August 2006 - Nil


Male - 8 cases, Female - 7 cases

Age Range  
Less than 5 years - Nil
5 to 10 years - 15
More than 10 years - Nil


Symptoms



Abdominal pain - 15 cases
Vomiting

- 12 cases

Loose stools

- 7 cases

Fever

- 5 cases



WBC
- Less than 10,000/cmm
-100%
Polymorphs - Less than 70% -100%
ESR - Less than 20 -50%

- More than 20 -48%
Platelet count - Less than 3 Lakhs 15
Stool analysis (Pus cells) -Less than 5 15

Discussion
It is evident from this study that mesenteric lymphadenitis being a medical cause of acute abdomen could be the main differential diagnosis of acute appendicitis and any other surgical causes. The causes are often misdiagnosed for acute appendicitis and are taken for appendicectomy. According to study done in A.I.I.M.S. from January 2003 to September 2003, 40% of children who had undergone appendicectomy were found to have normal appendix by histopathology.

20% of children who underwent surgery for appendicitis were found to have mesenteric adenitis, with normal appendix.
Hence inquiry into the location, timing of onset, character, severity, duration and radiation of pain are all important points and must be viewed in the context of child's age.
Repeated clinical assessment of location, whether localized? Or diffuse, acute or chronic onset, aggravating or reliving factors, guarding (voluntary or involuntary), rigidity, radiation of pain on change of posture would give us the clinical diagnosis, which could be correlated or confirmed by ultrasound.
Grossly lymph nodes are enlarged often soft, the adjoining mesentery may be edematous without exudates.
Dr.Rao, in 1995 specified the criteria of 3 or more clustered lymph nodes in right lower quadrant.
Incidental mesenteric adenitis in more common in children, while appendicitis in common in more common in adults.
By presentation pain precedes vomiting in surgical condition and reverse is true in medical condition like mesenteric lymphadenitis.
As per the literature, in our study we found that mesenteric lymphadenitis are rare in above 10 yrs of age and has equal gender distribution.

From our study, it also indicates that surgical opinion are asked for;
-severe or increasing abdominal pain with progressive signs of deterioration
-involuntary abdominal guarding/rigidity
-rebound abdominal tenderness
-abdominal pain without obvious etiology
Conclusion
Mesenteric lymphadenitis found to be important differential diagnosis, in acute abdomen in particular acute appendicitis. This could be diagnosed on repeated on repeated clinical assessment. Mesenteric lymphadenitis is found to be self limiting, and probably viral etiology. If diagnosed correctly, any interventional surgery can be avoided.

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