[Sclerosing peritonitis]

A forensic case of abdominal cocoon syndrome

The term "cocoon syndrome" defines a sclerosing encapsulating peritonitis (SEP) that involves a chronic fibrotic inflammatory reaction of the parietal peritoneum and of the viscera leading to a complete sclerosis. The cocoon that is formed causes an incarceration of the intestinal loops with severe complications leading to high mortality. We are presenting the case of a 15-year-old young man that underwent surgery for appendectomy and that was evaluated for having a regular abdominal state. During the post-surgery period, however, several episodes of intestinal occlusion required further surgical interventions leading to a right hemicolectomy. The presence of a fibrotic-adhesive ligneous peritonitis with blended intestinal loops, severely thickened walls, and intestinal scaring stenosis was observed during his second surgical operation. A stenosis of the colostomy led to a worsening of the vital signs of the young man with the onset of a cardiac failure and subsequent decease. Macroscopic autopsy examination and histological analysis confirmed the severe obstructive adhesive encapsulating abdominal context allowing to trace back the cause of death to a cocoon syndrome. Since no predisposing factor could be found, we hypothesized that this case could be characterized by an excessive peritoneal reactivity due to surgical appendectomy. Cocoon syndrome is a rare pathology, and its microscopic features are seldomly observed and could be underestimated. We present a directly observed case with a very substantial macroscopic and microscopic context.

Idiopathic sclerosing encapsulating peritonitis: a case in an adolescent girl

Encapsulating peritonitis or "abdominal cocoon" is characterised by part or all of the digestive tube being encased in a thick membrane forming a sort of "cocoon". In addition to secondary forms related to peritoneal dialysis or those with drug related, inflammatory or tumour aetiologies, rare idiopathic forms have been described. We report here a case of an idiopathic form in a 15-year-old adolescent girl.

Epidemiology of abdominal cocoon in China during the past 14 years

AIM: To study the epidemiological features of abdominal cocoon and its diagnosis and treatment in China during the past 14 years.

METHODS: Reports on abdominal cocoon published from January 1994 to June 2007 were retrieved from various databases, such as Chinese Medical Current Content (CBM) and National Knowledge Infrastructure (CNKI). The epidemiological features of abdominal cocoon and its diagnosis and treatment were analyzed.

RESULTS: A total of 776 patients with abdominal cocoon were reported in China during the past 14 years. The male to female ratio was approximately 1:1.37. The mean age of patients at the time of their diagnosis was 29.3 years. Fifty-seven percent of the patients were distributed in East China. Intestinal obstruction of different types was the main clinical manifestation in 91.5% of the patients, diffuse abdominal cocoon was found in 68.3% of the patients, and greater omentum was absent in 40.5% of the patients. Capsule resection was the main procedure for the treatment of abdominal cocoon.

CONCLUSION: Abdominal cocoon is more common in East China and is difficult to diagnose before operation. Capsule removal and adhesion release are effective against the disease.

[Mesenteric panniculitis]

Mesenteric panniculitis also named retractile mesenterite is a rare tumor-like lesion that thickens and shortens the mesentery. It is characterized by the association of inflammation, necrosis or fibrosis involving the adipose tissue of the bowel mesentery. The pathophysiology of this disease remains unclear despite associations with inflammatory diseases or malignancies, especially lymphomas that have been described. When symptomatic, patients may present with abdominal pain, palpable abdominal mass or intestinal obstruction. The disease remains asymptomatic in 30 to 50% of cases. Abdominal CT plays an important role in suggesting the diagnosis and can be useful in distinguishing the several conditions that can mimic mesenteric panniculitis. Nevertheless, pathologic examination of surgical excisional biopsies or sometimes percutaneous biopsies remains necessary to confirm the diagnosis and exclude an underlying infection or malignancy. Medical treatment may consist of therapy with anti inflammatory or immunosuppressive agents and can be proposed in highly symptomatic diseases. Surgical treatment should be exclusively attempted when intestinal obstruction or ischemia occur. Most of the time, it consists in intestinal derivation or segmental resection because complete excision of the lesions is often not possible. Mesenteric panniculitis usually has an uneventful clinical course and resolves spontaneously in a variable delay.