Abdominal cocoon: preoperative diagnosis on CT

Abstract

A 23-year-old man presented to the emergency department with a history of recurrent episodes of subacute intestinal obstruction. Palpation revealed a firm, non-tender, mobile, non-pulsatile mass of size 8–10 cm with indistinct margins and smooth surface in the hypogastrium. Contrast-enhanced CT scan of the abdomen showed clumping of the small bowel loops within a well-defined membrane-like structure without dilatation or thickening of bowel loops. The patient underwent a laparotomy with incision of the membrane and separation of all the small bowel loops inside the cocoon. Abdominal cocoon is the idiopathic variety of sclerosing encapsulating peritonitis and is an unusual cause of acute or subacute intestinal obstruction. Clinical diagnosis is difficult because of non-specific symptoms. CT has facilitated accurate preoperative diagnosis, long before the patient presents with full-fledged symptoms of acute intestinal obstruction. CT scan plays a significant role in excluding the secondary causes and helps in patient management.

Abdominal Cocoon or Encapsulating Peritoneal Sclerosis: A Rare Cause of Small Bowel Obstruction

“…Several causes have been associated with the now more common entity of secondary EPS, although the exact mechanism remains unclear. These factors include prolonged peritoneal dialysis (the most common factor), peritoneal irritation due to surgical intervention or abdominal trauma, ventriculo-peritoneal shunts, infections (particularly peritoneal tuberculosis), prolonged practolol or propranolol (beta-blockers) therapy, intraperitoneal drug administration (e.g., chemotherapy or povidone), endometriosis, liver cirrhosis and neoplasms with peritoneal seeding (e.g., ovarian tumours), and connective tissue diseases (e.g., sarcoidosis and SLE) [2,5]. Our patient had no medical history suggestive of any condition associated with secondary EPS, which leads us to believe that it might have been a case of primary EPS.…”

“…Other presenting complaints include anorexia, weight loss, malnutrition and constipation [3,4] . More than 50% of patients present with a palpable non-tender abdominal mass [5] . Abdominal ascites might be detected in long-standing cases.…”

“…Management Surgery has been the traditional method to manage most cases, with laparotomy being the preferred approach. The role of laparoscopy is mostly limited to diagnostic purposes in doubtful cases, but in theory, it can be used for treatment only based on the surgeon's confidence and experience [5] . The typical intraoperative finding is encasement of the bowel (in its entirety or just partially) by a thick cocoon of fibrocartilaginous tissue.…”

“…This condition is one of the 6% of rare causes of bowel obstruction. In most cases it is diagnosed either by exclusion or as an intraoperative finding [5] . The aetiology of this condition is unclear but histopathological examination shows features of chronic inflammation.…”

Sclerosing encapsulating peritonitis presenting with paroxysmal abdominal pain and strangulated mechanical bowel obstruction

“…Nonetheless, recent technological advances in surgical laparoscopic techniques and computed tomography (CT) have made the preoperative diagnosis of SEP possible. [ 11 ] The best treatment approach for SEP is complete surgical resection and adhesiolysis. At present, the knowledge on SEP is not very thorough, and more research data needs to be accumulated to deepen the understanding.…”