Encapsulating peritoneal sclerosis with hemorrhagic necrosis mimicking ovarian malignancy

Abstract

Encapsulating peritoneal sclerosis (EPS) is a rare, but often fatal, complication of peritoneal dialysis, characterized by marked inflammation and severe fibrosis of the peritoneum. Thick adhesions resembling a cocoon encapsulate the intestinal loops. Hence, this condition is also referred to as "abdominal cocooning". EPS usually occurs after long periods of peritoneal dialysis. Patients with EPS demonstrate nonspecific symptoms such as bowel obstruction, loss of appetite, fever, nausea, vomiting, ascites, constipation, diarrhea, and weight loss. The diagnosis of EPS is usually made by computed tomography (CT) scan. Another ancillary procedure is peritoneoscopy. During laparotomy, the classic picture of abdominal cocooning is seen [1e8]. We present a case of a 65-yearold woman, gravida 4 para 3, who was operated with the impression of ovarian malignancy based on the imaging survey, but found to have EPS with hemorrhagic necrosis.A 65-year-old woman, gravida 4 para 3, who was in menopause for 18 years, was admitted for vaginal spotting and abdominal distention. Physical examination revealed an abdominalepelvic mass extending up to the level of the umbilicus. She was also noted to have nonspecific symptoms such as nausea, constipation, and poor appetite for the past number of years. The patient was diagnosed with end-stage renal disease for diabetic nephropathy. She had been on peritoneal dialysis for 13 years, but has been on hemodialysis for the past 4 years.On admission, the patient was weak and pale, but alert. Abdominal examination revealed a soft, tympanic abdomen with hypoactive bowel sounds. On palpation, the mass extended up to the umbilicus. It was cystic in nature and had restricted mobility. There was no guarding or rigidity. The CA-125 level was 72.8 U/mL. Transvaginal ultrasound showed a large pelvic mass with thick confluent septum and scattered calcifications, but the origin could not be specified (Fig. 1). The initial impression was an ovarian tumor. CT scan revealed a centrally necrotic cystic mass measuring 19.7 cm  16 cm, with irregular borders and calcifications.Dilated bowel loops were pushed to the peripheral portion of the abdominal wall (Fig. 2). Several soft tissue lesions were noted on the peripheral portion of the mass. Another cystic mass with calcifications measuring 12 cm at the anterior hepatic surface was also noted. The uterus was anteverted, and other adnexal structures could not be clearly identified. No lymph node enlargement was noted.Under the impression of ovarian cancer, laparoscopic staging surgery was planned. The view from the laparoscope showed the parietal peritoneum and the fibrous bands that covered the bowel (Fig. 3). The laparoscopic approach had to be abandoned, as adequate pneumoperitoneum could not be created because the parietal peritoneum was seen loosely adherent to the bowel and omentum like a flimsy membrane. Intestinal loops were encapsulated together by thick adhesions. Conversion to laparotomy was performed. Upon opening, there was a white, thick-walled ...