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Prevalence, factors associated, and histological pattern of incidental enlarged mesenteric lymph nodes among patients undergoing laparotomy at referral hospitals in central Tanzania; a cross-sectional study

BMC Surgery volume 25, Article number: 61 (2025) Cite this article

Abstract

Background

There are different causes of Incidental Enlarged MesentericLlymph Nodes (IMLN) found during laparotomy, which most of the time influence the postoperative course. These causes are variable across the globe, but the node pattern in our locality and the factors associated with the incidental enlarged mesenteric lymph nodes are not yet established. Due to the lack of an established protocol in our locality, there have been some mismanaged cases that led to several postoperative complications. Therefore, this study aimed to evaluate the prevalence, factors associated with, and histological pattern of incidental mesenteric lymphadenopathy.

Methodology

The 885 patients were conveniently recruited in the study. The incidental enlarged mesenteric lymph nodes were taken during surgery, processed and histologically analyzed as per pathological protocol. Obtained data were filled out and analyzed using SPSS version 27. Binary logistic regression was used to examine clinical data, with a significance level of p < 0.05, to determine the factors linked to lymph node enlargement.

Results

It was seen that 58.08% of the study group, with a mean age of 30.5 years, were between the ages of 21 and 40. Males accounted for 71.53% of the total, while 252 individuals were female, giving a M: F ratio of 2.5:1. The prevalence of incidental mesenteric lymphadenopathy was 12.5%. Associated factors of Incidental Mesenteric Lymphadenopathy in this study were HIV, smoking, nomadic pastoralism, and surgical indication. HIV-positive patients were 7 times more likely to have IML with a 95% CI [2.975, 16.741], and (p < .0001), smokers were 10 times more likely to have IMLN, 95% CI [3.745, 28.458], and (p < .0001), nomadic pastoralists were 3 times more likely to have IMLN, 95% CI [1.647, 5.882], and (p < .0001) and patients who were operated upon peritonitis were 3 times more likely to have IMLN, 95% CI [2.040, 7.572], and (p < .0001). Of the incidental lymphadenopathy (N = 111), 23.42% had granulomatous tuberculous lesions, and 9.01% of lymph nodes harbored malignancy. About 47% of patients had histologically confirmed reactive lymph nodes, while 20.72% had an inflammatory pattern.

Conclusion and recommendation

The major factors associated with incidental enlarged mesenteric lymph nodes are smoking, comorbidities such as HIV and diabetes, malignancies, and infections such as tuberculosis. The common histological pattern is reactive nodes though there are potentially fatal nodes that were discovered including those that harbored malignancies and infections such as Tuberculosis. Therefore, to rule out potentially fatal illnesses and comorbidities that can be treated early to spare patients from extended hospital stays and potentially disastrous results, comprehensive investigations should be conducted in the event of incidentally enlarged mesenteric lymph nodes are found during a laparotomy.

Peer Review reports

Background

Within the mesentery, a tissue fold that connects the intestines to the posterior abdominal wall, are mesenteric lymph nodes, essential parts of the lymphatic system [1]. These nodes are essential for immune surveillance because they filter lymph fluid, and trap pathogens, foreign objects, and cancer cells [1]. Incidental findings refer to unexpected discoveries made during medical examinations or procedures conducted for unrelated reasons [2]. Thus, mesenteric lymph nodes that are incidentally discovered to be enlarged during a laparotomy a surgical operation typically used for other diagnostic or therapeutic purposes are known as incidental enlarged mesenteric lymph nodes (IMLNs) [3].

Incidental enlarged mesenteric lymph nodes may have a heavy burden on account of the possible effects on patient's outcomes and care [4]. Finding enlarged lymph nodes may require further diagnostic testing, such as a histological analysis, to identify the underlying cause [5]. Extra procedures and possible requirements in the original condition's final treatment can result from incidentally found enlarged mesenteric lymph nodes [6].

Surgeons usually detect incidental enlarged mesenteric lymph nodes during laparotomy by palpating and visually inspecting the patient [7]. During a standard abdominal cavity examination, these nodes might be observed as well [8]. The size and appearance of the nodes are the main determining factors for enlargement; nodes with a diameter of more than 1 cm are regarded as enlarged [9]. Preoperative imaging tests like computed tomography (CT) scan, magnetic resonance imaging (MRI), or intraoperative ultrasonography may occasionally result in incidental discovery [10, 11].

It is important to identify incidental enlarged mesenteric lymph nodes for several reasons. First of all, these nodes' existence can offer crucial diagnostic hints regarding underlying diseases that might not have been recognized in the past [12]. They might, for instance, point to an underlying infection, inflammatory condition, or cancer, necessitating more investigations and suitable treatment [13]. Second, histological analysis of these nodes can aid in the distinction between benign and malignant lymph node enlargement sources, hence directing further treatment decisions [5]. For example, cancer would demand a different therapeutic approach, whereas benign reactive hyperplasia might not require any additional care [14].

To address this challenge, the goal of this study was to provide knowledge on the prevalence, risk factors as well and patterns of incidental mesenteric lymphadenopathy considered to be unusual and requiring additional assessment in addition to providing expert opinion on the management of this condition. Bridging this knowledge gap will also assist in identifying modifiable risk factors for this disorder, which may give clinicians important information on how to lower the risk factors and find the most appropriate treatment.

Materials and methods

This was a hospital-based cross-sectional study done from July 2023 to June 2024. This study was conducted in Dodoma (Benjamin Mkapa Hospital & Dodoma regional referral hospital), and Iringa regional referral hospital. Benjamin Mkapa Hospital is a central zone referral hospital, while the other two hospitals serve as referral hospitals in Iringa and Dodoma regions respectively. This study included all candidates who underwent emergency exploratory laparotomy in the respective hospitals. All patients who underwent laparotomy at the respective hospitals, stable patients who could tolerate the procedure, and patients who consented to laparotomy were included in the study. Patients with confirmed Peritoneal Tuberculosis, patients with known abdominal malignancies, and patients with advanced or neglected peritonitis were excluded from the study. In this study, mesenteric lymphadenopathy and histopathological patterns were considered as dependent variables. Exposure variables were Demographic factors and clinical factors. The sample size was calculated using this formula of a single proportion, \(\begin{array}{ll}\mathrm n=\\&\end{array}\frac{\mathrm Z^2\mathrm P(100-\mathrm P)}{\mathrm\varepsilon^2}\) where; n = was the minimum sample size required Z = standard normal deviation set at 1.96 (corresponding to a confidence level of 95%), ε = marginal error to be used of 5.0%,

P = prevalence of patients with incidental enlarged mesenteric lymphadenopathy was found to be 38.8% (Islam et al., 2014). Therefore, the proposed sample size was 365 patients. During the study period, 894 patients had exploratory laparotomies in the hospitals where the study was being carried out. Nine patients were excluded from the study (had confirmed malignancies), 885 were recruited. A convenient sampling technique was used. Subjects were selected among and available consented and who had met the inclusion criteria for the study then were enrolled.

Data collection

Patients' characteristics such as age (years), sex, comorbidities, smoking tendency, preoperative diagnosis, history of medications, fever, weight loss, and history of previous surgeries were obtained directly from the patient. No effort was made to diagnose mesenteric lymphadenopathy preoperative, as these patients were sick requiring emergency surgery.

All patients were resuscitated according to the hospitals’ protocols until they were hemodynamically stable. They were prepared for surgery, a written informed consent for both an emergency laparotomy and lymph node sampling was obtained. All patients were approached in the same manner, in which, a standard extended midline incision was made; the primary pathology was dealt with according to protocol. After abdominal lavage, the mesentery was thoroughly palpated to identify any enlarged lymph nodes. When found dissection and removal of at least 3 significantly enlarged nodes more than 1 cm in diameter was done, [9] using surgical instruments, and the obtained lymph node samples were stored in a sample collection bottle filled with 10% formaldehyde solution for fixing, then transported to the laboratory for histopathological workups.

Post-operative, patients were followed for one week to observe for any complications following lymph node dissection such as bleeding, infection, and iatrogenic intestinal perforation. If there were any complications, the patient was managed accordingly.

Histological examination

Following tissue fixation, the specimen may have required further dissection in the laboratory to obtain an appropriate area for examination. The obtained specimen after dissection underwent the next step called dehydration, where it was immersed in a series of alcohol solutions to remove water from the specimen since the next step in its preparation required no water at all because the paraffin wax used was hydrophobic.

The next step in the laboratory was clearing, where a clearing reagent was used to impart optical clarity or transparency to the tissue due to its relatively high refractive index.

The next step was wax infiltration, where a suitable histological wax was used, the last step was tissue embedding or blocking out, in this step, the specimen was formed into a block, which was then clamped into a microtome for section cutting after it was examined for histopathology under a high power field microscope with magnification up to times 400.

A tissue biopsy with positive histopathological results suggestive of malignancy was referred to oncologists after surgical resection for further management. For those that were suggestive of any other pathology, patients were subjected to a respective treatment or channeled to a respective department, respectively.

The workups were requested by filling out an investigation form and the results were interpreted and attached to a respective document of a patient.

Data processing and analysis

The data collected was directly filled into a spreadsheet and checked for correctness and consistency to avoid errors. Descriptive characteristics of the study population, prevalence, and risk factors for IMLN were examined using frequency and tables, while numerical variables were summarized as means with standard deviation. The chi-square test of association was used to test the association of the risk factors. Multivariable statistical analysis was used to identify factors associated with incidental mesenteric lymphadenopathy, including the use of regression models to analyze the connection between risk factors and the result of interest. Data was collected and analyzed using Statistical Package for the Social Sciences version 27.

Results

It was discovered that of the 885, 111 of these patients had incidental enlarged mesenteric lymph nodes. It was also seen that, 58.08% of the study group, or most patients, were between the ages of 21 and 40, of the total participants, 633 persons were male, accounting for 71.53% of the total, while 252 individuals were female, making up 28.47%, with M: F ratio being 2.5:1. Pastoral tribes accounted for 5.87% of the total population. Peasants were found to have mesenteric lymphadenopathy (58.42%) compared to individuals in other occupations, whereby individuals who were self-employed or engaged in business (24.18%), and a very small percentage are employed (1.92%) or unemployed (15.48%).

The prevalence of mesenteric lymphadenopathy was 12.5%.

HIV was present in a significant portion of individuals (21.60%). It was observed that 3.60% of these patients had hypertension and diabetes mellitus. Smoking was relatively common, with 22.50% of patients having a history of smoking. The vast majority of patients (96.40%) had not had previous abdominal surgery. In this patient population, peritonitis was the most common cause of surgery (87.40% of cases). With 12.60% of cases, intestinal obstruction (IO) was a less frequent surgical indication. It was found that 45.90% of the patients had a fever history. Also, 24.30% had weight loss, and 41.40 percent of the patients were taking medications. Other characteristics are summarized in Tables 1 and 2.

Table 1 Demographic characteristics of the patients undergoing laparotomy found with lymphadenopathy
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Table 2 Comorbidities and surgical characteristics of the patients undergoing laparotomy found with lymphadenopathy
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Under sex, there doesn't appear to be a significant association (p = 0.9295) between gender and enlarged lymph nodes. In contrast, for variables like Tribes, Occupation, HIV status, Diabetes, Hypertension, history of medication, weight loss, fever, and others, there are significant associations (p < 0.05).

Regarding tribes, it was observed that among patients with incidentally enlarged mesenteric lymph nodes, patients from non-pastoral tribes have a lower likelihood of having incidental enlarged mesenteric lymph nodes (11.52%) compared to patients from pastoral tribes (28.85%). Regarding occupation of the patients, it was observed that among patients with incidentally enlarged mesenteric lymph nodes, a large proportion were peasants (17.79%) followed by employed (17.65%). Concerning comorbidities, it was observed that among patients with incidentally enlarged mesenteric lymph nodes, a large proportion had comorbidities HIV (43.64%), Diabetes mellitus (44.44%), and Hypertension (44.44%). The findings also showed that among patients with incidental mesenteric lymphadenopathy, a large proportion had a history of fever, using medication, weight loss, and no previous abdominal surgery. Lastly, the results show that among patients with incidental enlarged mesenteric lymph nodes, a large proportion had Peritonitis (18.00%). (see Table 3).

Table 3 Factors associated with incidental enlarged mesenteric lymph nodes among patients undergoing laparotomy
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Binary logistic regression was used to assess the factors associated with incidental enlarged mesenteric lymph nodes. The results show that after controlling for other variables, incidental mesenteric lymphadenopathy was statically significantly associated pastoral tribes (p < 0.0001), Peasants (p < 0.0003), HIV (p < 0.0001), Diabetes Mellitus (p = 0.0356), smoking (p < 0.0001) and surgical indication (p < 0.0001).

Compared to people from non-pastoral tribes, members of pastoral tribes have a higher percentage of incidentally enlarged mesenteric lymph nodes (AOR = 3.112, p < 0.0001). Regarding the occupation of the patients, it was observed that Peasants are more likely to present with incidentally enlarged mesenteric lymphadenopathy (AOR = 16.460, p = 0.0003) compared to other patients. The findings also show that HIV-positive patients are more likely to have incidental mesenteric lymphadenopathy (AOR = 7.057, p < 0.0001) compared to those with no HIV. In addition to that, diabetic patients were more likely to have incidental enlarged mesenteric lymph nodes (AOR = 6.564, p = 0.0356) compared to non-diabetic patients. Smoking patients are more likely to have incidental mesenteric lymphadenopathy (AOR = 10.324, p < 0.0001) compared to non-smokers. The findings show that Peritonitis patients were more likely to have incidental enlarged mesenteric lymph nodes (AOR = 3.930, p < 0.0001) compared to Intestinal obstruction patients. See Table 4.

Table 4 Binary logistic regression for the factors associated with incidental enlarged mesenteric lymph nodes among patients undergoing laparotomy
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Of the incidental lymphadenopathy (N = 111), 23.42% had granulomatous Tuberculous lesions, and 9.01% of lymph nodes harbored malignancy. About 47% of patients had histologically confirmed reactive lymph nodes while 20.72% had an inflammatory pattern.

Discussion

Prevalence of incidental enlarged mesenteric lymph nodes

The prevalence of incidental mesenteric lymphadenopathy of 12.5% in this study differs from the study by Vayner et al., [15] which showed the prevalence of mesenteric lymphadenopathy to be 61.4%, Gawad et al., [16], found a slightly higher prevalence of 68% while Unlu et al., [8] reported a lower prevalence of 7%. In all studies, patients were characteristically different from the index study explaining the differences, while in the study by Vayner, the methodology included only children, possibly increasing the prevalence. Comparatively speaking, our study and the others' findings are comparable in that mesenteric lymphadenopathy was more common in the male gender in both studies [15].

The prevalence in this study also differs from another study done in children, whereby a higher prevalence of 61.4% of enlarged mesenteric lymph nodes was observed in children involved in the study [17]. The higher prevalence difference could be because mesenteric lymphadenopathy is a more common finding in children than the adult population which was most common in our study population [18].

Another higher prevalence of mesenteric lymph node enlargement was in 72.1% of the cases and 13.4% of controls in Sri Lanka in children who presented with chronic abdominal pain. This differs from our study probably due to the differences in the study population. Unlike our adult study population, it is similar to our study that lymphadenopathy was prevalent in the male gender same as in our study, this could be due to higher testosterone levels in males, which could potentially impact the behavior of the lymphatic system and immune responses.

Factors associated with incidental enlarged mesenteric lymph nodes

The nomadic pastoral tribes were the most afflicted group in the study population, a statistically significant (p < 0.0001) difference, which may have been caused by several elements inherent in their way of life and cultural customs. Katale et al., [19] indicated that Maasai people who are nomadic pastoralists are at considerable risk due to their custom of consuming raw milk, which puts them at risk for diseases like tuberculosis (TB). Bovine mycobacterium bovis is a species of bacteria that can cause tuberculosis (TB) in humans when consumed through unpasteurized dairy products [20]. Nomadic pastoralism is a factor associated with several diseases, in a study regarding epidemic-prone diseases among pastoralists in Uganda, it was revealed that nomadic pastoralism is a factor associated with the occurrence and reoccurrence of epidemic diseases [21]. These similarities with the index study are probably due to the similar manner of living among pastoral tribes.

Compared to other occupational groups, peasants, or those involved in manual labor and small-scale farming, were shown to have a higher incidence of incidentally enlarged mesenteric lymph nodes. Dwivedi et al., [22] indicated that lower socioeconomic position is frequently associated with inferior living circumstances, inadequate nutrition, and restricted access to healthcare which put one at greater risk for infections and other illnesses that might lead to lymphadenopathy, consistent with the findings of this study. The danger may be further increased by the physically demanding nature of peasants and possible exposure to environmental infections as shown by Donnelly et al., [23] that there is an association between low socioeconomic status and increased risks of infection and hospitalization in people of low socioeconomic status such as peasants in the index study. These studies are in line with the index study possibly because peasants in this study are from poor socioeconomic societies.

Incidental enlarged mesenteric lymph nodes were more common in patients whose surgical indication was peritonitis. This finding is similar to a study by Felten et al., [24], that indicated peritoneal contamination by intestinal contents can result in mesenteric lymphadenopathy. The relationship between peritonitis and lymph node enlargement is highlighted by the inflammatory process as well as the presence of bacteria or other irritants in the abdominal cavity which is the site of a possible intermediate phase in the immune response [25]. This is in line with the index study possibly because most patients being attended at these referral facilities have neglected peritonitis warranting prolonged exposure to irritants in the abdominal cavity leading to mesenteric lymphadenopathy.

In the index study, incidental enlarged mesenteric lymph nodes were more common in patients with comorbidities, such as HIV and diabetes than in patients without these illnesses. A similar observation was seen in one study that indicated HIV was a risk factor for developing mesenteric lymphadenopathy [18]. It is known that HIV is an immune system-attacking virus, increasing susceptibility to infections, including those that might result in lymphadenopathy as reported by Deeks et al., [26] and Taramasso et al., [27]. Similar to this, diabetes weakens the immune system and makes people affected more prone to infections [28, 29]. Enlarged lymph nodes are more common in the immunocompromised, which can be explained by the chronic nature of these diseases and their effect on the body's defenses against infections [30]. These studies support the findings of the index study perhaps as a consequence of the immunosuppressive nature of these comorbidities.

Smoking appears to be associated with an increased likelihood of incidentally enlarged mesenteric lymph nodes compared to non-smokers. Similarly, in one study on mesenteric lymphadenitis as a presenting feature of Whipple's disease, smoking was also found to be one of the risk factors [31]. The difference with the index study is that only patients with Whipple's disease were recruited. Yamaguchi et al., [32] indicated that the immune system is known to be negatively impacted by smoking, and one of these impacts is that it hinders the body's capacity to mount efficient defenses. Similarly, Jiang et al., [33] indicated that smokers may be more vulnerable to infections and inflammatory diseases that cause lymph node enlargement as a result of this immunosuppressive effect. Furthermore, smoking has been linked to long-term respiratory disorders, which may have an indirect impact on the lymphatic system and how it functions [34]. The above studies are in line with the index study’s findings perhaps because smokers are prone to immunosuppression which makes them susceptible to abdominal infections and consequently mesenteric lymphadenopathy.

Histological pattern of incidental enlarged mesenteric lymph nodes

Pathological investigation of the 111 patients with incidentally enlarged mesenteric lymph nodes showed a varied pattern of underlying diseases. Interestingly, Tuberculous granulomatous lesions were present in 26 patients (23.42%), a strong diagnostic of peritoneal tuberculosis (TB). In line with the index study, a prevalence of 31–58% of abdominal TB was reported by Rossi et al., [35]. The similarity to the index study is that the cohort involved was from a developing country. The index study is also in line with a study that was done in India that indicated Tuberculous lymphadenopathy being the commonest form of abdominal TB showing the importance of thorough investigations when mesenteric lymphadenopathy is noted [36]. Fillion et al., [37] reported a higher prevalence of 67% of peritoneal TB in their study that aimed to describe the characteristics and treatment of patients presenting with abdominal tuberculosis. This differs from our study probably because a smaller number of patients (21) were included in their study.

On the other hand, it was discovered that 10 individuals (9.01%) had cancer linked to their enlarged mesenteric lymph nodes. Lucey B.C et al., [38] indicated that colorectal cancer and pancreatic carcinoma are frequently associated with local mesenteric lymphadenopathy in line with this study giving a clue that enlarged mesenteric lymph nodes should be investigated. Given that malignancies might have substantial prognostic and therapeutic implications, this subgroup is an important component of incidental findings during laparotomies [39]. Primary tumors arising in the mesenteric lymph nodes as well as secondary metastatic lesions are among the types of malignancies found incidentally during laparotomy [40]. These findings, in line with other studies, suggest that incidental findings of mesenteric lymphadenopathy warrant close observation and comprehensive histological assessment to guarantee an early and precise cancer diagnosis [1]. Same as in the index study, both primary and secondary mesenteric tumors were observed necessitating the importance of histological examination.

Reactive mesenteric lymph nodes were present in 52 patients (46.84%) of the total number of patients. Usually, reactive lymphadenopathy is an indication of a benign condition that is occurring elsewhere in the body, such as an infection or inflammation that does not need surgery [14]. However, it is important to further investigate the reactive lymph histological pattern [41]. To distinguish between more dangerous illnesses that may first present similarly and benign reactive alterations, it is imperative to identify and closely monitor these patients with reactive lymphadenopathy [41].

Additionally, the mesenteric lymph nodes of 23 individuals (20.72%) showed signs of chronic nonspecific inflammation which are non-specific hyperplasia and edema. Patients with long-term inflammatory diseases including Crohn's disease, ulcerative colitis, and other types of inflammatory bowel disease (IBD) usually present with this lymph node pattern [8]. Significant lymph node enlargement caused by mesentery inflammation may be symptomatic or incidentally detected [14]. Treating the underlying inflammatory illness in these patients entails using biological medicines, immunosuppressants, and corticosteroids [13]. Monitoring closely and following up often are necessary to control illness flare-ups and avoid consequences [22].

These results suggest the potential diversity and complexity of incidental mesenteric lymphadenopathy.. Previous studies indicate that granulomatous, malignant, reactive, and inflammatory patterns might each require distinct diagnostic approaches [42]. It is impossible to exaggerate the significance of carefully examining incidental findings made during laparotomies since doing so makes it possible to identify potentially dangerous underlying diseases that could otherwise go undetected in line with another study [41].

Enhanced collaboration between surgeons, pathologists, infectious disease specialists, oncologists, and gastroenterologists could support more comprehensive assessment and patient care. Better patient outcomes, proper therapy, and accurate diagnosis are made possible by this integrated approach [43].

Conclusion

The major factors associated with incidental enlarged mesenteric lymph nodes are smoking, comorbidities such as HIV and diabetes, malignancies, and infections such as tuberculosis. The common histological pattern is reactive nodes though there are potentially fatal nodes that were discovered including those that harbored malignancies and infections such as Tuberculosis. Therefore, to rule out potentially fatal illnesses and comorbidities that can be treated early to spare patients from extended hospital stays and potentially disastrous results, comprehensive investigations should be conducted in the event of incidentally enlarged mesenteric lymph nodes found during a laparotomy.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

BMH:

Benjamin Mkapa Hospital

DRRH:

Dodoma Regional Referral Hospital

HIV:

Human Immunodeficiency Virus

IO:

Intestinal obstruction

IRRH:

Iringa Regional Referral Hospital

LN:

Lymph node

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Acknowledgements

We acknowledge Dr. Francis Zerd ( Pathologist), Mr. and Mrs Josephat Rweyemamu.

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  1. Department Surgery, The University Of Dodoma, Dodoma, Tanzania

    Devotha Josephat Rweyemamu & Masumbuko Yatembela Mwashambwa

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  1. Devotha Josephat Rweyemamu
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Contributions

DR- conception and design of the study, acquisition, and analysis of data, drafting the manuscript, and submission of the manuscript. MYM- conception and design of the study, acquisition, and analysis of data, finalizing of the manuscript and correspondence. All authors hereby declare that they read and approved the final manuscript before submission for publication.

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Correspondence to Masumbuko Yatembela Mwashambwa.

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Ethical approval was obtained from The Dodoma University Research Review Ethics Committee (Ref. No. MA. 84/261/73/22). All participants who accepted to be recruited in the study signed a written consent form.

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Rweyemamu, D.J., Mwashambwa, M.Y. Prevalence, factors associated, and histological pattern of incidental enlarged mesenteric lymph nodes among patients undergoing laparotomy at referral hospitals in central Tanzania; a cross-sectional study. BMC Surg 25, 61 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12893-024-02745-0

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Keywords

BMC Surgery

ISSN: 1471-2482

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