Sclerosing encapsulating peritonitis: A rare cause of intestinal obstruction in 2 patients

Sclerosing encapsulating peritonitis is a very rare cause of intestinal obstruction. It usually follows peritoneal dialysis. The idiopathic form is also called abdominal cocoon and is more common in tropical and subtropical regions. We hereby present the clinical histories and imaging findings of 2 confirmed cases of sclerosing encapsulating peritonitis who presented with chronic symptoms of bowel obstruction.

Abdominal cocoon syndrome-a rare culprit behind small bowel ischemia and obstruction: Three case reports

BACKGROUND

Abdominal cocoon syndrome (ACS) represents a category within sclerosing encapsulating peritonitis, characterized by the encapsulation of internal organs with a fibrous, cocoon-like membrane of unknown origin, resulting in bowel obstruction and ischemia. Diagnosing this condition before surgery poses a challenge, often requiring confirmation during laparotomy. In this context, we depict three instances of ACS: One linked to intestinal obstruction, the second exclusively manifesting as intestinal ischemia without any obstruction, and the final case involving a discrepancy between the radiologist and the surgeon.

CASE SUMMARY

Three male patients, aged 53, 58, and 61 originating from Northern Thailand, arrived at our medical facility complaining of abdominal pain without any prior surgeries. Their vital signs remained stable during the assessment. The diagnosis of abdominal cocoon was confirmed through abdominal computed tomography (CT) before surgery. In the first case, the CT scan revealed capsules around the small bowel loops, showing no enhancement, along with mesenteric congestion affecting both small and large bowel loops, without a clear obstruction. The second case showed intestinal obstruction due to an encapsulated capsule on the CT scan. In the final case, a patient presented with recurring abdominal pain. Initially, the radiologist suspected enteritis as the cause after the CT scan. However, a detailed review led the surgeon to suspect encapsulating peritoneal sclerosis (ACS) and subsequently perform surgery. The surgical procedure involved complete removal of the encapsulating structure, resection of a portion of the small bowel, and end-to-end anastomosis. No complications occurred during surgery, and the patients had a smooth recovery after surgery, eventually discharged in good health. The histopathological examination of the fibrous membrane (cocoon) across all cases consistently revealed the presence of fibro-collagenous tissue, without any indications of malignancy.

CONCLUSION

Individuals diagnosed with abdominal cocoons commonly manifest vague symptoms of abdominal discomfort. An elevated degree of clinical suspicion, combined with the application of appropriate radiological evaluations, markedly improves the probability of identifying the abdominal cocoon before surgical intervention. In cases of complete bowel obstruction or ischemia, the established norm is the comprehensive removal of the peritoneal sac as part of standard care. Resection with intestinal anastomosis is advised solely when ischemia and gangrene have been confirmed.

Surgical management of sclerosing encapsulating peritonitis (SEP) secondary to tuberculosis: A case report and review of the literature

INTRODUCTION

Sclerosing encapsulating peritonitis (SEP), commonly known as abdominal cocoon syndrome (ACS), is considered one of the rare causes of bowel obstruction [1].

CASE PRESENTATION

In this article, we report the case of a 20-year-old male patient with a 6-month history of recurrent colicky right-sided upper abdominal pain accompanied by nausea, vomiting and bloating, which gradually increased in severity and frequency. The contrast-enhanced abdominal computed tomography suggested a small bowel obstruction with a differential diagnosis of SEP. Later exploratory laparotomy and histopathological examination confirmed the diagnosis of ACS. Intraoperative adhesiolysis was performed and the patient's symptoms resolved.

DISCUSSION

This syndrome is characterised by the formation of a fibrous-collagenous membrane that partially or completely engulfs the small intestine, less commonly the colon and other abdominal organs. SEP is most commonly associated with long-term peritoneal dialysis, although drugs, peritoneal infection and systemic inflammatory disorders have been implicated. Patients often present with symptoms of partial bowel obstruction, which is difficult to diagnose before laparotomy. Of the available investigations, contrast-enhanced CT of the abdomen is the most sensitive, showing a fibrous sac-like membrane covering the intestinal loops and the fluid collection. Definitive treatment includes excision and adhesiolysis.

CONCLUSION

This article presents a rare case and focuses on the management of this pathology with a review of the literature.

Abdominal cocoon: A rare case report of a small bowel obstruction

INTRODUCTION

Sclerosing encapsulating peritonitis (SEP), or abdominal cocoon, is a remarkably rare entity. It consists of a fibrous layer or cocoon-like sac encasing, in most cases, the small bowel. The lack of specific symptoms makes preoperative diagnosis challenging.

CASE PRESENTATION

A 50-year-old patient, with no history of abdominal surgery or medical diseases, was admitted for symptoms of small bowel obstruction. On examination, the patient was underweight with a BMI of 18 kg/m2. Vital signs were stable. His abdomen was mildly distended and soft. Abdominal CT scan showed signs in favor of a left paraduodenal hernia with incarcerated small bowel loops. Intraoperatively, the small bowels were encapsulated in a cocoon-like structure formed by thick fibrous tissue associated with multiple adhesions. Careful adhesiolysis with complete resection of the membrane was performed. The postoperative course was uneventful. One year later, the patient was symptom-free.

DISCUSSION

SEP is thought to be a persistent inflammatory disorder due to a cause that remains unidentified. It is divided into two categories based on its etiology: primary and secondary. The most common mode of SEP revelation is bowel obstruction. Because there is no clear consensus on SEP management, the therapeutic approach typically follows the management strategy of bowel obstruction.

CONCLUSION

SEP is an uncommon cause of bowel obstruction. Preoperative detection can be challenging in the absence of pathognomonic signs. Treatment is based on surgery, specifically entailing complete excision of the cocoon and adhesiolysis.

Idiopathic Sclerosing Encapsulating Peritonitis - Preoperative diagnostic challenges: A case report and review of literature

INTRODUCTION AND IMPORTANCE

Idiopathic Sclerosing Encapsulating Peritonitis (ISEP) is an uncommon condition of intestinal bowel obstruction due to encapsulation of the abdominal organs in a thick fibro-collagenous membrane. The case presented here describes the emergency acute presentation of septic peritonitis discovered intraoperatively upon laparotomy.

CASE PRESENTATION

A middle-aged woman was admitted to the emergency department and presented with generalized colicky abdominal pain associated with repetitive vomiting, abdominal distention, and absolute constipation. A digital rectal examination revealed an empty rectum and a bilious output was observed in the nasogastric tube. Abdominal X-Ray demonstrated multiple air-fluid levels with no air under the diaphragm. The patient was treated with fluid therapy and antibiotics intravenously (IV).

CLINICAL DISCUSSION

The clinical impression of acute-on-chronic intestinal obstruction with peritonitis and the possibility of bowel strangulation was made. Emergency exploratory laparotomy revealed viable bowel loops encased in thickened fibrous capsules covering the entire abdominal viscera establishing the existence of ISEP. The fibrous capsule layer was excised out in small pieces from all the abdominal organs excluding stomach through extensive adhesiolysis without loop resection.

CONCLUSION

The emergency presentation of acute peritonitis observed in this study could only be identified through diagnostic laparoscopy and differential radiological imaging techniques. Further, better reporting of such rare cases may help clinicians understand the different clinical features that could indicate the occurrence of ISEP.

An incidental intra-operative finding of sclerosing encapsulating peritonitis, "abdominal cocoon" in an emergency presentation of small bowel obstruction, a case report

INTRODUCTION AND IMPORTANCE

Sclerosing encapsulating peritonitis (SEP) is a disease characterized by a chronic inflammatory process in which the small intestines are encased by a dense fibrocollagenous membrane. In this article, we report a 57 year old male who presented with bowel obstruction secondary to sclerosing encapsulating peritonitis with an initial imaging suggesting internal hernia.

CASE PRESENTATION

A 57-year-old male, who presented to the emergency department at our center with a chronic persistent nausea and vomiting, associated with anorexia, constipation and weight loss, CT scan showed a transition zone seen at the duodeno-jejunal (DJ) junction and findings suggesting internal hernia, he was treated conservatively initially followed by a diagnostic laparoscopy that was converted to open with intraoperative findings of intra-abdominal cocoon rather than an internal hernia, managed with adhesolysis and discharged home in stable good condition.

CLINICAL DISCUSSION

There are multiple factors that could attribute to PSEP including cytokines, fibroblasts, and angiogenic factors, such patients might be asymptomatic or presenting with GI obstruction symptoms. The diagnosis of PSEP varying from abdominal x rays to contrast enhanced CT scan.

CONCLUSION

The management of PSEP depends on the presentation and should be individualized, weather conservative medical or surgical approach can be used.

Bowel inflammatory presentations on computed tomography in adult patients with severe aplastic anemia during flared inflammatory episodes

BACKGROUND

Patients with severe aplastic anemia (SAA) frequently present with inflammatory episodes, and during flared inflammatory episodes, hematopoietic function is further exacerbated. The gastrointestinal tract is the most common site for infectious and inflammatory diseases, and its structural and functional features confer on it the most potent capacity to affect hematopoietic and immune functions. Computed tomography (CT) is a readily accessible approach to provide highly useful information in detecting morphological changes and guiding further work-ups.

AIM

To explore CT imaging presentations of gut inflammatory damage in adult SAA patients during inflammatory episodes.

METHODS

We retrospectively evaluated the abdominal CT imaging presentations of 17 hospitalized adult patients with SAA in search of the inflammatory niche when they presented with systemic inflammatory stress and exacerbated hematopoietic function. In this descriptive manuscript, the characteristic images that suggested the presence of gastrointestinal inflammatory damage and related imaging presentations of individual patients were enumerated, analyzed and described.

RESULTS

All eligible patients with SAA had CT imaging abnormalities that suggested the presence of an impaired intestinal barrier and increased epithelial permeability. The inflammatory damages were concurrently present in the small intestine, the ileocecal region and the large intestines. Some readily identified imaging signs, such as bowel wall thickening with mural stratification (“water holo sign”, “fat holo sign”, intramural gas and subserosal pneumatosis) and mesenteric fat proliferation (fat stranding and “creeping fat sign”), fibrotic bowel wall thickening, “balloon sign”, rugged colonic configuration, heterogeneity in the bowel wall texture, and adhered and clustered small bowel loop (including various patterns of “abdominal cocoon”), occurred at a high incidence, which suggested that the damaged gastrointestinal tract is a common inflammatory niche responsible for the systemic inflammatory stresses and the exacerbated hematopoietic failure in patients with SAA. Particularly, the “fat holo sign” was present in 7 patients, a rugged colonic configuration was present in 10 patients, the adhesive bowel loop was present in 15 patients, and extraintestinal manifestations suggestive of tuberculosis infections were present in 5 patients. According to the imaging features, a suggestive diagnosis of Crohn’s disease was made in 5 patients, ulcerative colitis in 1 patient, chronic periappendiceal abscess in 1 patient, and tuberculosis infection in 5 patients. Other patients were diagnosed with chronic enteroclolitis with acutely aggravated inflammatory damage.

CONCLUSION

Patients with SAA had CT imaging patterns that suggested the presence of active chronic inflammatory conditions and aggravated inflammatory damage during flared inflammatory episodes.

IgG4 related sclerosing encapsulating peritonitis with cocoon formation: An unusual and undescribed presentation

IgG4-related sclerosing mesenteritis is a rare disease of mesentery of an unknown etiology which shows a constellation of histopathologic findings of lymphoplasmacytic inflammation with IgG4-positive plasma cells and marked fibrosis. This chronic inflammatory condition of mesentery forming an abdominal cocoon has never been described before to the best of our knowledge. Here, we report a patient with a history of subacute small bowel obstruction who was found to have an intra-abdominal encapsulating mass in the right iliac fossa and was finally diagnosed as IgG4-related sclerosing encapsulating peritonitis (abdominal cocoon) based on peroperative findings, histology and immunohistochemistry.

Surgical timing for primary encapsulating peritoneal sclerosis: A case report and review of literature

BACKGROUND

Primary encapsulating peritoneal sclerosis (EPS) is a rare but devastating disease that causes fibrocollagenous cocoon-like encapsulation of the bowel, resulting in bowel obstruction. The pathogenesis, prevention, and treatment strategies of EPS remain unclear so far. Since most patients are diagnosed during exploratory laparotomy, for the non-surgically diagnosed patients with primary EPS, the surgical timing is also uncertain.

CASE SUMMARY

A 44-year-old female patient was referred to our center on September 6, 2021, with complaints of abdominal distention and bilious vomiting for 2 d. Physical examination revealed that the vital signs were stable, and the abdomen was slightly distended. Computerized tomography scan showed a conglomerate of multiple intestinal loops encapsulated in a thick sac-like membrane, which was surrounded by abdominal ascites. The patient was diagnosed with idiopathic EPS. Recovery was observed after abdominal paracentesis, and the patient was discharged on September 13 after the resumption of a normal diet. This case raised a question: When should an exploratory laparotomy be performed on patients who are non-surgically diagnosed with EPS. As a result, we conducted a review of the literature on the clinical manifestations, intraoperative findings, surgical methods, and therapeutic effects of EPS.

CONCLUSION

Recurrent intestinal obstructions and abdominal mass combined with the imaging of encapsulated bowel are helpful in diagnosing idiopathic EPS. Small intestinal resection should be avoided.

Abdominal cocoon in children: A case report and review of literature

BACKGROUND

Abdominal cocoon or “encapsulating peritoneal sclerosis” (EPS) is an uncommon and rare cause of intestinal obstruction. Only a few cases have been reported in paediatric patients. Typically, EPS is described as the primary form in young adolescent girls from tropical and subtropical countries because of viral peritonitis due to retrograde menstruation or a history of peritoneal dialysis. Most patients are asymptomatic or present with abdominal pain, which is likely to occur secondary to subacute bowel obstruction. Findings at imaging, such as ultrasound, computed tomography, and magnetic resonance imaging, are often nonspecific. When diagnosed, EPS is characterized by total or partial encasement of the bowel within a thick fibrocollagenous membrane that envelopes the small intestine in the form of a cocoon because of chronic intraabdominal fibroinflammatory processes. The membrane forms a fibrous tissue sheet that covers, fixes, and finely constricts the gut, compromising its motility.

CASE SUMMARY

We present a case of EPS in a 12-year-old boy 8 wk after primary surgery for resection of symptomatic jejunal angiodysplasia. There was no history of peritoneal dialysis or drug intake.

CONCLUSION

In this report, we sought to highlight the diagnostic, surgical, and histopathological characteristics and review the current literature on EPS in paediatric patients.

An unusual case of intestinal obstruction due to abdominal cocoon: A case report

INTRODUCTION AND IMPORTANCE

Abdominal cocoon (AC) or Encapsulating Peritoneal Sclerosis (EPS) is a rare cause of bowel obstruction and due to non-specific presentation, it can be misdiagnosed and often mistreated.

CASE PRESENTATION

We present the case of 42 years male with a history suggestive of complete small bowel obstruction (SBO) without a history of pulmonary tuberculosis (TB) or peritoneal dialysis. CT imaging as well as the intraoperative finding of a cocoon membrane encasing the small bowel led to the diagnosis of abdominal cocoon.

CLINICAL DISCUSSION

Abdominal cocoon can be idiopathic or secondary to peritoneal dialysis, tuberculosis, or other rare causes. Patients usually present with features of SBO with varying severity. Diagnosis is aided by imaging investigations mainly CT scan and management is primarily surgical and usually involves adhesiolysis, total removal of the membrane with or without bowel loop resection.

CONCLUSION

Diagnosis of abdominal cocoon warrants awareness of the disease and a high index of suspicion of the treating clinician in patients with intestinal obstruction and an abdominal lump without a history of previous abdominal surgery. CT can guide diagnosis and early operative management seems to bear the best outcomes.

A case of encapsulating peritoneal sclerosis in a patient with chronic schistosomiasis

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Chronic schistosomiasis leads to immune dysregulation and organ fibrosis.

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Encapsulating peritoneal sclerosis (EPS) is a potentially fatal condition, if left untreated.

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Inflammatory pathways promote mesothelial proliferation leading to EPS development.

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EPS has never been described in patients with chronic schistosomiasis.

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A rare case of a patient with concurrent schistosomiasis and EPS is presented here.

Encapsulating peritoneal sclerosis (EPS) is a debilitating condition, mainly associated with long-term peritoneal dialysis, where up-regulation of intra-abdominal inflammatory pathways leads to a fibrocollagenous peritoneal membrane formation resembling a cocoon. EPS causes intestinal encapsulation leading to bowel obstruction and dilatation. Chronic schistosomiasis is characterized by dysregulation of pro-inflammatory and anti-inflammatory cytokines. EPS has never been reported before in patients with chronic schistosomiasis. We report the first, to our knowledge, case of a 57-year-old male originated from Burkina Faso with chronic intestinal and urogenital schistosomiasis and EPS. Although causality cannot be established solely by this case, we hypothesize that EPS may be the result of chronic inflammatory activation, due to immune dysregulation driven by chronic schistosomiasis. The potential pathogenetic linkage between these two conditions should be further explored.

A rare case of intestinal obstruction: Sclerosing encapsulating peritonitis of unknown cause

Sclerosing encapsulating peritonitis (SEP) is characterized by the partial or complete enclosing of the small intestines by a thick fibro-collagenous membrane, which can cause recurrent intestinal obstruction. SEP is a clinically rare disease, and the major risk factor is peritoneal dialysis (PD). Early diagnosis of SEP is an important factor in the patient's prognosis, but it is clinically difficult. A 52-year-old woman visited the emergency department (ED) with a 2-day history of abdominal pain and vomiting. She had a history of liver cirrhosis with chronic hepatitis B, but no history of PD, and she underwent a biopsy of the peritoneum by laparoscopy a month ago. On physical examination, there were peritoneal irritation signs on the right lower quadrant (RLQ). Abdominal computed tomography (CT) showed dilated small intestinal loops clustered in the RLQ, which were surrounded by a sac-like, thick fibrous membrane. Based on CT findings, small intestinal obstruction due to SEP was early diagnosed in the ED. Emergency physicians should include SEP in the differential diagnosis of the cause of intestinal obstruction. Abdominal CT is a useful modality for the early diagnosis of SEP in the ED.

Abdominal cocoon with bilateral cryptorchidism and seminoma in the right testis: a case report and review of literature

Background

Abdominal cocoon is a rare peritoneal lesion and is difficult to diagnose because of its lack of special clinical manifestations. Until now, there is no case report of abdominal cocoon combined with cryptorchidism and seminoma.

Case presentation

A case of abdominal cocoon with cryptorchidism and seminoma was diagnosed and treated in our hospital. The patient had no symptoms except occasional abdominal pain. He underwent laparoscopy because of bilateral cryptorchidism and seminoma in the right testis. During the surgery, he was diagnosed with abdominal cocoon due to the thick fibrous tissues which was tightly adhered and encased part of intestine like a cocoon. Enterolysis and bilateral cryptochiectomy were performed after the diagnosis and nutritional and symptomatic support was provided after the surgery. The patient recovered well and was discharged soon. The postoperative pathological examination confirmed the presence of bilateral cryptorchidism and seminoma in the patient’s right testis.

Conclusion

There are only a handful of cases where a patient has both abdominal cocoon and cryptorchidism. Since the etiologies of both diseases remain unknown, further research is required to investigate effective diagnosis and treatment for the diseases and explore the potential connection between the two diseases.

Tuberculous abdominal cocoon mimicking peritoneal carcinomatosis

Background

Tuberculous abdominal cocoon is an uncommon manifestation of abdominal tuberculosis. As a rare clinical entity, it is often encountered unexpectedly in patients with small intestinal obstruction. Here we presented a rare case of tuberculous abdominal cocoon which was suspected to be peritoneal carcinomatosis and was finally diagnosed by laparoscopy.

Case presentation

A 47-year-old man developed small intestinal obstruction and massive ascites that did not resolve with conservative management. Surgical exploration revealed a fibrous sheath covering the small-bowel, and pathologic assessment of biopsies confirmed intra-abdominal tuberculous infection. After antituberculosis therapy, the ascites has greatly diminished and the patient was functioning normally.

Conclusion

Preoperative diagnosis of tuberculous abdominal cocoon is a true challenge. Early diagnostic peritoneal biopsy should be recommended and surgery is usually unnecessary if definitive diagnosis can be made.

Encapsulating peritoneal sclerosis

Encapsulating peritoneal sclerosis (EPS) is a debilitating condition characterized by a fibrocollagenous membrane encasing the small intestine, resulting in recurrent small bowel obstructions. EPS is most commonly associated with long-term peritoneal dialysis, though medications, peritoneal infection, and systemic inflammatory disorders have been implicated. Many cases remain idiopathic. Diagnosis is often delayed given the rarity of the disorder combined with non-specific symptoms and laboratory findings. Although cross-sectional imaging with computed tomography of the abdomen can be suggestive of the disorder, many patients undergo exploratory laparotomy for diagnosis. Mortality approaches 50% one year after diagnosis. Treatment for EPS involves treating the underlying condition or eliminating possible inciting agents (i.e. peritoneal dialysis, medications, infections) and nutritional support, frequently with total parenteral nutrition. EPS-specific treatment depends on the disease stage. In the inflammatory stage, corticosteroids are the treatment of choice, while in the fibrotic stage, tamoxifen may be beneficial. In practice, distinguishing between stages may be difficult and both may be used. Surgical intervention, consisting of peritonectomy and enterolysis, is time-consuming and high-risk and is reserved for situations in which conservative medical therapy fails in institutions with surgical expertise in this area. Herein we review the available literature of the etiology, pathogenesis, diagnosis, and treatment of this rare, but potentially devastating disease.

Sclerosing encapsulating peritonitis after living-donor liver transplantation: A case series, Kyoto experience

Sclerosing encapsulating peritonitis (SEP), or abdominal cocoon is a rare cause of intestinal obstruction, and still etiology remains unknown. We report a series of 4 patients with abdominal cocoon, and all the 4 patients had previously undergone living-donor liver transplantation (LDLT). There was no evidence of SEP before and during LDLT. At the time of diagnosis of SEP, 3 out of 4 patients had ascites. First and fourth patients had multiple episodes or attacks of cholangitis, which were managed by percutaneous transhepatic biliary drainage and hepaticojejunostomy, respectively. All 4 patients presented with intestinal obstruction and 3 of them underwent a successful operation. The fourth patient died due to liver failure and complications of the SEP. The first 3 patients are doing well without SEP recurrence. Our experience suggest that the prognosis of SEP is poor in patients with poor graft liver functions after LDLT.

Peritoneal encapsulation syndrome: A case report and literature review

INTRODUCTION

Peritoneal encapsulation is an infrequently described congenital anomaly that results in formation of an accessory peritoneal membrane. The case presented below is unique in that it illustrates one of the rare complications of this condition. It is important for clinicians to be aware of this condition and its complications in order to limit potential morbidity and mortality.

PRESENTATION OF CASE

We report on an eleven-year-old boy without prior abdominal symptoms who presented with an acute abdomen after an episode of intense physical exertion. At laparotomy, gangrenous small bowel loops were identified extruding from an opening in a peritoneal sac consistent with peritoneal encapsulation syndrome. All gangrenous bowel (mostly ileum) was resected. The sac was excised and a primary jejunum to ascending colon anastomosis was created. The patient did well post operatively and was subsequently discharged.

DISCUSSION

Peritoneal encapsulation is an aberration of peritoneal development that is frequently confused with other visceral encapsulation syndromes of inflammatory origin. Due to its mostly asymptomatic course, its true incidence remains unknown. An appreciation of the condition and its potential complications allows surgeons to take appropriate action in the event of incidental discovery at laparoscopy or laparotomy.

CONCLUSION

Peritoneal encapsulation is a rare, mostly asymptomatic, surgical finding which may predispose patients to an acute abdominal crisis.

Abdominal Cocoon Syndrome: a Rare Cause for Recurrent Abdominal Pain

Abdominal cocoon syndrome, or sclerosing peritonitis, is a rare condition characterized by encasement of small bowel loops by a thick fibrous scar. It most commonly presents as nonspecific vague chronic abdominal pain and weight loss, and is difficult to recognize clinically until the patient develops symptoms of bowel obstruction. We present a case of abdominal cocoon syndrome in a 65-year-old female and describe its clinical, imaging, and pathologic features.

Abdominal Cocoon: "Cauliflower Sign" on CT Scan

A case of an abdominal cocoon that showed a characteristic "cauliflower sign" on CT scan has been presented.

Encapsulating peritoneal sclerosis as a late complication of peritoneal dialysis

Introduction

Encapsulating peritoneal sclerosis (EPS) is a rare cause of intestinal obstruction which is characterized by fibrotic encapsulation of the bowel. Although its pathogenesis is still not clear, many etiological factors have been stated.

Presentation of case

In this report, we present a 26-year old woman with peritoneal dialysis related EPS. Because of the unresolving intestinal obstructive symptoms, she underwent surgical intervention in which the thick dense whitish membranous sac was excised from the surrounding intestine along with adhesiolysis. She recovered uneventfully. She is symptom-free on the eight months of follow-up.

Discussion

EPS should be born in mind as a complication of the long term peritoneal dialysis in patients with progressive obstructive ileus and recurrent peritonitis. Its treatment either medically or surgically varies depending on the stage of this entity.

Conclusion

Early identification of EPS is important in order to achieve better prognosis.

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We presented the patient experienced surgery because of encapsulating peritoneal sclerosis (EPS).

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EPS should be born in mind as a complication of the long term peritoneal dialysis.

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Diagnosis is primarily based on clinical finding, then generally confirmed by CT.

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Early identification of EPS is important in order to achieve better prognosis.

Cocoon abdomen - A rare cause of intestinal obstruction

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Sclerosing encapsulating peritonitis persistent low-grade peritonitis.

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Most cases are discovered incidentally on laparotomy.

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Computed tomography or barium meal may be helpful in preoperative diagnosis.

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Simple removal of the membrane and lysis of the adhesions produces optimal outcome. Bowel resection is indicated only when the intestine is nonviable.

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A high index of suspicion and appropriate radiology can prevent ‘surprises’ and unnecessary bowel resection.

INTRODUCTION

Sclerosing encapsulating peritonitis or abdominal cocoon is a rare condition of unknown etiology in which intestinal obstruction result from encasement of variable length of bowel by dense fibro collagenous membrane.

PRESENTATION OF CASE

A case of young male is reported who presented with features of small bowel obstruction with tender mass in the right iliac fossa. CT scan suggested features of internal herniation. On exploration, he was found to have small intestine, large intestine, stomach and liver covered with a thick cocoon like membrane. The membrane was gently peeled off the small intestine. The patient recovered well and was discharged on an oral diet.

DISCUSSION

Preoperative diagnosis of abdominal cocoon is difficult and most cases are discovered incidentally on laparotomy. Contrast enhanced computed tomography or barium meal may be helpful in preoperative diagnosis. Surgical treatment is the main stay of treatment for this condition. Simple removal of the membrane and lysis of the adhesions produces optimal outcome. Bowel resection is indicated only when the intestine is nonviable.

CONCLUSION

A high index of suspicion and appropriate radiology can prevent ‘surprises’ and unnecessary bowel resection. Simple removal of the membrane gives a good outcome.

Post trauma abdominal cocoon

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Patient with past history of abdominal blunt trauma presented with subacute intestinal obstruction caused by abdominal cocoon.

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Common aetiology for abdominal cocoon is subclinical peritonitis, in this case due to an unnoticed injury during blunt trauma.

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Diagnosis can made preoperatively with imaging.

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Treatment by adhesiolysis in obstructed cases.

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Recurrences are uncommon.

Abdominal cocoon or sclerosing peritonitis refers to a rare cause of intestinal obstruction due to formation of a membrane encasing the bowel. We report a case of abdominal cocoon post blunt trauma abdomen. The patient presented with a history of subacute intestinal obstruction and a mobile abdomen lump. Abdominal cocoon was diagnosed on computed tomography. He underwent adhesiolysis with excision of membrane.

Idiopathic sclerosing encapsulating peritonitis (abdominal cocoon) in adult male. A case report

INTRODUCTION

Abdominal cocoon (sclerosing encapsulating peritonitis) (SEP) is a rare condition, mostly affecting adolescent girls living in tropical/subtropical region. Its etiology is unknown. It may cause acute or sub-acute intestinal obstruction.

PRESENTATION OF CASE

We report here a 39 year old male who complained of long standing colicky abdominal pain, with significant weight loss. Abdomen CT scan showed clumping of ileal loops at the level of umbilicus, with a thin capsule surrounding it. Laparoscopy revealed abdominal cocoon, biopsy of which showed dense hypocellular fibro-collagenous tissue with no neoplastic or granulomatous process. Excision of fibrous tissue and release of adhesions was done. Patient was symptoms free after five months follow up.

DISCUSSION

Abdominal exploration is usually needed for the diagnosis and treatment of abdominal cocoon. A thick fibrotic peritoneal wrapping of the bowel is usually found. Complete recovery is the result in majority of cases after surgical removal of the wrap causing the cocoon.

CONCLUSION

Primary sclerosing encapsulating peritonitis (cocoon abdomen) diagnosis needs a high index of suspicion, as signs and symptoms are nonspecific and imaging findings are not always conclusive. Careful excision of the accessory peritoneal sac and lysis of adhesions between bowels is the best treatment. Prognosis is generally good.

Idiopathic sclerosing encapsulating peritonitis (abdominal cocoon) in adult male. A case report

INTRODUCTION

Abdominal cocoon (sclerosing encapsulating peritonitis) (SEP) is a rare condition, mostly affecting adolescent girls living in tropical/subtropical region. Its etiology is unknown. It may cause acute or sub-acute intestinal obstruction.

PRESENTATION OF CASE

We report here a 39 year old male who complained of long standing colicky abdominal pain, with significant weight loss. Abdomen CT scan showed clumping of ileal loops at the level of umbilicus, with a thin capsule surrounding it. Laparoscopy revealed abdominal cocoon, biopsy of which showed dense hypocellular fibro-collagenous tissue with no neoplastic or granulomatous process. Excision of fibrous tissue and release of adhesions was done. Patient was symptoms free after five months follow up.

DISCUSSION

Abdominal exploration is usually needed for the diagnosis and treatment of abdominal cocoon. A thick fibrotic peritoneal wrapping of the bowel is usually found. Complete recovery is the result in majority of cases after surgical removal of the wrap causing the cocoon.

CONCLUSION

Primary sclerosing encapsulating peritonitis (cocoon abdomen) diagnosis needs a high index of suspicion, as signs and symptoms are nonspecific and imaging findings are not always conclusive. Careful excision of the accessory peritoneal sac and lysis of adhesions between bowels is the best treatment. Prognosis is generally good.

Perforated GIST in Jejunum - A Rare Cause of Abdominal Cocoon

Gastrointestinal stromal tumours [GISTs] are rare but they commonly arise in stomach, and small or large intestines. They are usually accompanied with gastrointestinal bleeding. We are reporting a case of GIST which occurred in a 52-year-old male,who presented with acute abdomen. On laparotomy, the entire segment of jejunum was found to be partially encased in fibrocollagenous tissue, which formed a cocoon. Moreover, the intestine showed diffuse thickening with multiple tumour masses, which is an uncommon gross finding in GIST. This case report highlights variable clinical and morphological manifestations of GIST. Awareness on its rare clinical manifestations, including abdominal cocoon, may help in making an early diagnosis and providing timely appropriate treatment.

Idiopathic sclerosing encapsulating peritonitis (abdominal cocoon) in adult male. A case report

INTRODUCTION

Abdominal cocoon (sclerosing encapsulating peritonitis) (SEP) is a rare condition, mostly affecting adolescent girls living in tropical/subtropical region. Its etiology is unknown. It may cause acute or sub-acute intestinal obstruction.

PRESENTATION OF CASE

We report here a 39 year old male who complained of long standing colicky abdominal pain, with significant weight loss. Abdomen CT scan showed clumping of ileal loops at the level of umbilicus, with a thin capsule surrounding it. Laparoscopy revealed abdominal cocoon, biopsy of which showed dense hypocellular fibro-collagenous tissue with no neoplastic or granulomatous process. Excision of fibrous tissue and release of adhesions was done. Patient was symptoms free after five months follow up.

DISCUSSION

Abdominal exploration is usually needed for the diagnosis and treatment of abdominal cocoon. A thick fibrotic peritoneal wrapping of the bowel is usually found. Complete recovery is the result in majority of cases after surgical removal of the wrap causing the cocoon.

CONCLUSION

Primary sclerosing encapsulating peritonitis (cocoon abdomen) diagnosis needs a high index of suspicion, as signs and symptoms are nonspecific and imaging findings are not always conclusive. Careful excision of the accessory peritoneal sac and lysis of adhesions between bowels is the best treatment. Prognosis is generally good.

[Not Available]

“Peritonitis fibrosa incapsulata”, first described in 1907, is a condition characterized by encasement of the bowel with a thick fibrous membrane. This condition was renamed as “abdominal cocoon” in 1978. It presents as small bowel obstruction clinically. 35 cases of abdominal cocoon have been reported in the literature over the last three decades. Abdominal cocoon is more common in adolescent girls from tropical countries. Various etiologies have been described, including tubercular. It is treated surgically by releasing the entrapped bowel. We report a laparoscopic experience of tubercular abdominal cocoon and review the literature.

Successful delivery after IVF-ET in an abdominal cocoon patient: case report and literature review

Abdominal cocoon (AC) is a rare condition of uncertain etiology. We report the case of a 29-year-old infertile Chinese woman with AC, who successfully got twin pregnancy and delivery through in vitro fertilization (IVF) and embryo transfer (ET). And this review discusses the current concepts of its pathogenesis, diagnosis and treatments. AC might lead to tubal infertility and IVF-ET would be the most effective remedy for the patients desiring pregnancy.

Abdominal cocoon secondary to meconium peritonitis in a neonate: a case report

Abdominal cocoon is a complete or partial encasement of intestines and rarely viscera by a fibrocollagenous sac which is usually formed by a nonspecific chronic inflammatory reaction. We report a case of abdominal cocoon in a 2-day-old neonate presenting with intestinal obstruction.

Malrotation and volvulus associated with heterotaxy syndrome

A 2-year-old boy with heterotaxy syndrome with associated polysplenia, ventricular septal defect, and malrotation of gut with volvulus is presented. There was delay in diagnosis due to the unusual plain abdominal radiography findings. At laparotomy, the midgut was also found to be enclosed in a thin transparent cocoon.

Abdominal cocoon: an unusual cause of subacute intestinal obstruction

We report an unusual cause of subacute intestinal obstruction in a young adolescent girl, which is a nontubercular abdominal cocoon. Barium meal follow-through revealed "cauliflower"-like appearance of small bowel. The patient underwent an exploratory laparotomy showing thick fibrous-like coverings which were encasing the small bowel loops to form an abdominal cocoon. Fibrocollagenous membrane was excised after adhesiolysis. Histopathological examination of membrane revealed fibrocollagenous membrane with hyaline deposition of nontubercular origin.

An unusual case in surgical emergency: Abdominal cocoon and its laparoscopic management

Small bowel obstruction associated with abdominal cocoon (AC) is a rarely encountered surgical emergency. This condition is characterised by a thick fibrous membrane which encases the small bowel partially or completely. It is usually difficult to be able to make a definitive diagnosis in the presence of obscure clinical and radiological findings. Diagnosis is usually made at laparotomy when the encasement of the small bowel within a cocoon-like sac is visualised. Here, we report on a 29-year-old male patient who presented with acute small bowel obstruction and was eventually diagnosed with AC at laparoscopy. In this case, laparoscopic excision of the fibrous sac and extensive adhesiolysis resulted in complete recovery. Although rare, the diagnosis of AC should be kept in cases of patients with intestinal obstruction combined with relevant imaging findings. Laparoscopy should also be considered for the management of this condition in suitable patients.

Post-traumatic intra-cocoon mesenteric tear: a case report

Sclerosing peritonitis, more commonly called abdominal cocoon, is a rare intra-peritoneal disease that is characterized by complete or partial encapsulation of the small intestine by a thick collagenous membrane. This disease mostly presents in the form of small bowel obstruction, however in our case the patient presented with intra-cocoon bleeding following a motor vehicle accident.

Abdominal cocoon as a rare cause of small bowel obstruction in an elderly man: report of a case and review of the literature

Abdominal cocoon is a rare cause of intestinal obstruction usually diagnosed incidentally at laparotomy. The cause and pathogenesis of the condition have not been elucidated. It primarily affects adolescent girls living in tropical and subtropical regions. Several earlier cases have been reported in males. We describe an 82-year-old man presenting with small bowel obstruction without history of previous abdominal surgery. He was treated by warfarin following aortic valve replacement. Abdominal cocoon was detected at laparotomy. Excision of membrane and lysis of adhesions led to relief of obstruction. Abdominal cocoon is a rare pathology that may be found in all kinds of populations. It may be a rare form of small bowel obstruction diagnosed during surgery in elderly patients.

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.

Idiopathic sclerosing encapsulating peritonitis (or abdominal cocoon): A report of 5 cases

Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction that is characterized by a thick grayish-white fibrotic membrane encasing the small bowel. SEP can be classified as idiopathic, also known as abdominal cocoon, or secondary. It is difficult to make a definite pre-operative diagnosis. We experienced five cases of abdominal cocoon, and the case files were reviewed retrospectively for the clinical presentation, operative findings and outcome. All the patients presented with acute, subacute and chronic intestinal obstruction. Computed tomography (CT) showed characteristic findings of small bowel loops congregated to the center of the abdomen encased by a soft-tissue density mantle in four cases. Four cases had an uneventful post-operative period, one case received second adhesiolysis due to persistent ileus. The imaging techniques may facilitate pre-operative diagnosis. Surgery is important in the management of SEP.

Diagnosis and treatment of four patients with primary abdominal cocoon accompanied with undescended testicle

AIM: To improve diagnosis and treatment of abdominal cocoon.

METHODS: Four patients with primary abdominal cocoon who were admitted to our hospital from January to December 2006 were analyzed. All patients were diagnosed with an acute intestinal obstruction. Unilateral undescended testicle was found in all patients during physical examination, and all underwent emergency operation.

RESULTS: The diagnosis of abdominal cocoon was confirmed after the operation. Partial or total capsule resection, lysis of any intestinal adhesion, and internal stenting was adopted in all four cases. All recovered uneventfully after surgery.

CONCLUSION: As patients with abdominal cocoon present with no specific clinical features, preoperative diagnosis is difficult. The possibility of abdominal cocoon should be considered when a patient with an intestinal obstruction has an undescended testicle. Laparotomy is an effective treatment for abdominal cocoon.