Presentation
Severe abdominal pain on and off for 6 months. Constipation, vomiting and anorexia. Clinically, a partially mobile mass is palpable in lower abdomen
Patient Data
Grouping of small bowel loops, mainly the distal jejunal, and ileal loops in the mid/lower abdomen in the midline. These are encapsulated by a thick enhancing fibrous membrane. The bowel loops within the lesion show minimal wall thickening and surrounding fat stranding. Proximal ileal loops fill with contrast but distal ileal loops are air-filled and show no oral contrast filling.
Mesenteric vessels are seen at the center of this ‘mass’ with bowel loops at the periphery. There is a prominent loculated fluid collection around the bowel loops within the encapsulated membrane at the left anterolateral aspect. The stomach, duodenum and proximal jejunal loops appear slightly dilated. The distal ileal loops are collapsed and show no oral contrast filling. Rectal contrast is seen filling the colonic loops and reaching up to the ileocecal junction.
Final diagnosis
Sclerosing encapsulating peritonitis or abdominal cocoon.
Intraoperatively, a whitish thick fibrous capsule was revealed which encased the distal jejunal and proximal ileal loops. Interloop adhesions and mild fluid were seen between these encapsulated bowel loops. Membrane dissection and extensive adhesiolysis were performed.
Case Discussion
Sclerosing encapsulating peritonitis or abdominal cocoon is a rare cause of small bowel obstruction characterized by the formation of a thick-walled sac or "cocoon". The wall of this cocoon is a thick fibrotic membrane and it contains small bowel loops, mesentery and some fluid. Internal adhesions are inevitable. Earlier it used to be an incidental or unsuspected finding during laparotomy but can be diagnosed pre-operatively with a high degree of suspicion.
Classification
idiopathic: usually seen in adolescent females or young adults, usually in tropical and subtropical countries
secondary: following tuberculosis, widespread peritonitis, intestinal perforation, prior abdominal surgery or ambulatory peritoneal dialysis for long duration
Pathology
It is characterized by the formation of a thick fibrotic membrane, encasing adherent small bowel loops and forming a sac or cocoon-like mass. This results in small bowel obstruction.
Presentation
palpable abdominal mass
acute or subacute small bowel obstruction
weight loss, nausea, vomting and anorexia
Management
Surgery is the treatment of choice and involves membrane dissection and adhesiolysis. Resection of non viable bowel loop can be done.
For a complete discussion on this topic please see: sclerosing encapsulating peritonitis.
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