Sclerosing peritonitis due to practolol: A report on 9 cases and their surgical management

Abstract

Nine patients with an unusual and serious intraabdominal complication of the beta-adrenergic blocking agent practolol seen since 1973 are reported. The striking and bizarre peritoneal changes induced by the drug have distinctive features that are not shown by other forms of peritoneal disease. The cases presented with small bowel obstruction, usually chronic in type and often associated with profound weight loss and an abdominal mass. Characteristic radiological features were present. The abnormalities at laparotomy were impressive, with a gross proliferation of the visceral peritoneum which formed a dense white cocoon which encased, constricted and markedly shortened the small bowel, usually from the duodenojejunal flexure to the ileocaecal valve. The obstruction was relieved by mobilizing the small bowel from the ensheathing tissue. Restoration of alimentary function after surgery was delayed but the long term result was satisfactory with full relief of symptoms and the absence of recurrent obstruction during the follow-up period. This complication may arise after treatment with the drug has been stopped, and although long term oral therapy has been discontinued, further cases will almost certainly present for some time to come.

Abdominal Cocoon

“…Terms such as sclerosing peritonitis [2], encapsulating peritonitis [3] and sclerosing encapsulating peritonitis [4] have also been used to describe this condition. A total of 35 cases have been reported, of which 25 were females and 10 males.…”

“…Some drugs especially beta adrenergic blockers like practolol have been suggested as a possible cause. Eltringherm et al [2] reported nine cases undergoing practolol therapy who developed peritonitis causing sclerosing peritonitis. Holland [4] reported sclerosing peritonitis in patients on chronic ambulatory peritoneal dialysis.…”

Review of the Literature and Description of a Case of Sclerosing Encapsulating Peritonitis Requiring Home Parenteral Nutrition

“…The exact mechanism by which beta blockers induce sclerosing peritonitis is unknown, but two suggested hypotheses include a possible allergic type reaction to the class of drug or perhaps an excess production of intraperitoneal collagen, which has been shown to be induced by these agents [2,14]. Several theories tried to explain this condition: when it was first described in adolescent girls from tropical and subtropical countries, this suggested retrograde menstruation as a cause [15], or retrograde viral infection via fallopian tubes [16], but appearance of the disease in males and older ages groups discards this hypothesis [17][18]. The presentation of SEP can be quite challenging ranging from abdominal pain, nausea, vomiting and vague symptoms to frank intestinal obstruction, most of the symptoms being related to partial small bowel obstruction.…”

A case of peritoneal encapsulation syndrome

“…Unlike this congenital form, the acquired disease (also called abdominal cocoon, or sclerosing encapsulated peritonitis) will have a thick greyish white membrane [2]. It usually presents with intestinal obstruction and has a mortality of 50% [2,4].…”

“…It usually presents with intestinal obstruction and has a mortality of 50% [2,4]. This condition is described in association with chronic ambulatory peritoneal dialysis, patients on long term practalol (beta blocker), tuberculous peritonitis, sarcoidosis, ventriculo-peritoneal and peritoneo-venous shunts and retrograde menstruation [2,4,5]. …”