|Ahead of print publication
Relevance of mesenteric lymphadenopathy in children detected on sonography
Ranjit Singh Lahel1, Amit Chail2
1 Department of Radiodiagnosis, Military Hospital Saugor, Sagar, Madhya Pradesh, India
2 Department of Psychiatry, Command Hospital Chandimandir, Panchkula, Haryana, India
|Date of Submission||02-Mar-2022|
|Date of Decision||02-Jun-2022|
|Date of Acceptance||21-Jun-2022|
|Date of Web Publication||05-Oct-2022|
Ranjit Singh Lahel,
Department of Radiodiagnosis, Military Hospital Saugor, Sagar, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Objective: Mesenteric lymphadenitis reflects the mesenteric lymph node (MLN) response to an underlying infection of uncertain etiology, usually viral. In children, enlarged MLNs are common findings detected during abdominal ultrasound, whether done for nonspecific pain abdomen or for unrelated clinical presentations. This study was conducted to determine the significance of mesenteric lymphadenopathy in asymptomatic children as compared to those with symptoms of acute abdominal pain or chronic abdominal pain (CAP). Methodology: A prospective hospital-based study was conducted among 72 children aged between 2 and 15 years. These children were referred from the outpatient/pediatric ward department for 1 year, for evaluation by abdominal ultrasonography. Children were grouped into three categories based on their clinical presentations as asymptomatic (controls), those with CAP, and those with acute abdomen. The sonographic findings were tabulated against each, with accounting of parameters such as size, number of enlarged nodes, and site of nodes. Pearson's Chi-square test was used to analyze ordinal variables between groups. About 95% confidence interval was selected with a P = 0.05 taken as statistically significant. Results: Significant enlarged MLNs were comparable in prevalence in all groups. The incidence of significant mesenteric lymphadenopathy in the CAP group was even less than in the control group. The Chi-square statistic was 2.5612. The P = 0.633718. The result is not statistically significant at P < 0.05. This indicates that MLNs on ultrasonography have no significant association with the clinical presentation in children. Conclusion: Our study indicates that reporting of enlarged mesenteric nodes on transabdominal sonography in children is not statistically significant with the clinical symptomatology.
Keywords: Chronic abdominal pain, mesenteric lymphadenopathy, sonography
| Introduction|| |
In the pediatric population, nonspecific mesenteric adenitis (often viral in origin) is the most common finding in a large proportion of cases of “medical pain abdomen” seen in clinical practice. In fact, many physicians currently consider mesenteric lymphadenitis a nondisease and its symptoms unexplained.
Mesenteric adenitis is categorized as primary (nonspecific) and secondary. Primary mesenteric adenitis is mostly right sided, without an identifiable acute inflammatory cause. Secondary mesenteric adenitis is associated with a demonstrable intra-abdominal inflammatory etiology.
Sonographic evaluation of these patients often shows enlarged mesenteric lymph nodes (MLNs). The diagnosis of lymph node enlargement by medical imaging is performed based on the size criterion. MLN enlargement is defined as a cluster of three or more lymph nodes with short-axis diameter >5 mm.,,,
The American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain (CAP) 2005 defined CAP as “long-lasting intermittent or constant abdominal pain that is either functional or organic.” Abdominal pain lasting for more than 1–2 months is considered chronic. CAP is common among schoolchildren and young adolescents with a prevalence ranging from 0.5% to 19%.
The consensus regarding the radiological and laboratory parameters which may be consistent with acute mesenteric lymphadenopathy in the literature is still lacking. We intend to study the correlation of sonographic finding of mesenteric lymphadenopathy with clinical presentation in the form of acute abdominal pain (AAP) or CAP.
| Methodology|| |
This was a hospital-based prospective study conducted in the radiology department enrolling children aged 2–15 years who reported for abdominal ultrasonography (USG) over a period of 1 year. Children referred from outpatient/in-patient departments for the evaluation of CAP or AAP were included as cases. The children who underwent abdominal sonography for indications other than pain abdomen were included in the control group.
Exclusion criteria included children with known causes of pain abdomen such as renal calculi, intussusception, abdominal tuberculosis, inflammatory bowel disease, and malignancy. Out of total of 113 children who underwent USG, 72 were finally included in the study. A total of 26 patients were in control group (asymptomatic), 34 in CAP group, and 12 in AAP group. All data were anonymized during the study. Consent was obtained from parent (s) for the study.
Size of lymph nodes >5 mm in short-axis diameter was taken as significant. Number of nodes and sites was tabulated. Lymph node clusters were classified into two groups based on numbers (<3 and >3). Pearson's Chi-square test was used in the analysis of ordinal variables and significance was assessed at 5% level with a P < 0.05 considered statistically significant.
| Results|| |
[Table 1] shows that the maximum proportion of affected children were from 5 to 10 years of age group, with girls contributing slightly more in incidence.
As shown in [Table 2], only a slightly increased incidence of mesenteric lymphadenopathy was found in AAP group. The incidence of significant mesenteric lymphadenopathy in CAP group was even less than the control group. The result is not significant at P < 0.05. This indicates that MLNs on USG have no significant association with the clinical presentation in children.
[Table 3] establishes that right iliac fossa was the most common site of mesenteric nodes among all three groups. This included both significant and nonsignificant lymph nodes.
|Table 3: Site of nodes in groups detected to have mesenteric lymph nodes|
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[Table 4] shows that cluster of nodes was also compared among cases and controls. However, there was no significant difference among the two groups.
[Table 5] shows the association between cluster of nodes and clinical presentation among cases. The result is significant at P < 0.05, indicating that clusters with more than three lymph nodes were significantly associated with AAP.
|Table 5: Cluster of nodes in cases (chronic abdominal pain and acute abdominal pain)|
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The additional findings such as small bowel wall thickening were found in two cases and free fluid in one case among children in AAP group.
| Discussion|| |
MLN enlargement can be due to a primary etiology or else can be secondarily attributed to other causes such as infective etiology, malignancy, and inflammatory bowel diseases. Moustaki et al. even postulated that abdominal pain can occur in cases of lobar/segmental pneumonia. In case no other abnormality is found during evaluation, enlarged MLNs are associated with primary mesenteric lymphadenitis. In many children, no organic cause for recurrent abdominal pain can be established, and even when an abnormality is detected, it may be difficult to link the finding to the abdominal pain. Due to shortcomings such as unreliable history and unpredictable clinical findings in pediatric age group, this often poses a diagnostic challenge.
Sonography is considered the most easily available and relevant imaging approach for the evaluation of MLNs in children. There is no requirement to get a computed tomography scan as sonography is reliable to make the diagnosis (only 9.51% false-positive results). However, there is no standardized reference interval of MLN size in asymptomatic children, and the diagnostic criterion currently used for MLN enlargement has been controversial.
As a step further to rationalize the size criteria of MLN, it has also been proposed in some studies to use the maximum short-axis diameter of 8–10 mm as the reference value for primary mesenteric lymphadenitis, as this will reduce the false-positive cases that eventually lead to unnecessary treatments.,,
Mesenteric adenitis is usually viral in origin and has self-limiting course., Mesenteric adenitis and postviral gastritis have a very certain occurrence following an acute viral infection. Therefore, overdependence on blood counts of the patient to correlate the severity of MLN enlargement is plausible to lead to aberrant conclusions. White blood cell count and C-reactive protein, which form a routine part of the diagnostic workup, are of very limited use in identifying patients with and without mesenteric lymphadenitis.
Similar to the findings in our study, Sivit et al. also found enlarged mesenteric nodes in all cases in their symptomatic study group in the right lower quadrant.
Healy and Graham in their study done on 50 children found that the largest mesenteric nodes in two children aged 13 and 14 years measured 23 and 24 mm, respectively. These children were however asymptomatic and follow-up evaluation established no underlying disease.
In view of the increased incidence of enlarged MLNs in asymptomatic and CAP cases in our study also, it is essential that thorough medical history, clinical examination, and goal-directed examinations should form basis of deciding further treatment of the child, rather than just going by the size criteria of MLN on sonography. It is also proposed to revise and lay down the cutoff limit for determining upon enlargement of mesenteric nodes as “significant” to 8 mm measured in short axis, to cut down upon the false-positive cases.
| Conclusion|| |
Reporting of enlarged mesenteric nodes on sonography needs to be viewed holistically in addition to rest of the findings on a case-to-case basis. The absolute generalization of enlarged mesenteric nodes detected on sonography being considered pathologic and requiring treatment needs to be reexamined and reflected upon in deciding the further treatment course for the patients.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Chanchlani R. Clinical profile and management of mesenteric lymphadenitis in children – Our experience. Int J Orthop Traumatol Surg Sci 2015;1:1-4.
Helbling R, Conficconi E, Wyttenbach M, Benetti C, Simonetti GD, Bianchetti MG, et al
. Acute nonspecific mesenteric lymphadenitis: More than “No Need for Surgery”. Biomed Res Int 2017;2017:9784565.
Cai B, Yi H, Zhang W. Reference intervals of mesenteric lymph node size according to lymphocyte counts in asymptomatic children. PLoS One 2020;15:e0228734.
Karmazyn B, Werner EA, Rejaie B, Applegate KE. Mesenteric lymph nodes in children: What is normal? Pediatr Radiol 2005;35:774-7.
Balakrishnan VS, Aroor S, Kumar S, Kini PG, Saseendran A. Mesenteric lymphadenopathy in children with chronic abdominal pain. Sri Lanka J Child Health 2018;47:348-53.
Özdamar MY, Karavaş E. Acute mesenteric lymphadenitis in children: Findings related to differential diagnosis and hospitalization. Arch Med Sci 2020;16:313-20.
Moustaki M, Zeis PM, Katsikari M, Fretzayas A, Grafakou O, Stabouli S, et al
. Mesenteric lymphadenopathy as a cause of abdominal pain in children with lobar or segmental pneumonia. Pediatr Pulmonol 2003;35:269-73.
Vayner N, Coret A, Polliack G, Weiss B, Hertz M. Mesenteric lymphadenopathy in children examined by US for chronic and/or recurrent abdominal pain. Pediatr Radiol 2003;33:864-7.
Shrestha AL, Adhikari G. Childhood mesenteric adenitis-The spectrum of findings. Kathmandu Univ Med J (KUMJ) 2021;19:47-51.
Lucey BC, Stuhlfaut JW, Soto JA. Mesenteric lymph nodes seen at imaging: Causes and significance. Radiographics 2005;25:351-65.
Sivit CJ, Newman KD, Chandra RS. Visualization of enlarged mesenteric lymph nodes at US examination. Clinical significance. Pediatr Radiol 1993;23:471-5.
Healy MV, Graham PM. Assessment of abdominal lymph nodes in a normal paediatric population: An ultrasound study. Australas Radiol 1993;37:171-2.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]