Abdominal cocoon: a surgical challenge

Abstract

Encapsulating peritoneal sclerosis (EPS) or sclerosing peritonitis best described as abdominal cocoon is a complex syndrome characterized by formation of a thick fibrocollagenous membrane that totally encloses the small intestinal loops. The etiology is varied and multifactorial. This complex disease is usually associated with continuous peritoneal dialysis (PD), tuberculosis, post renal transplant, or with long term use of beta blockers. A few cases may even be idiopathic in origin. The pathogenesis is attributed to conversion of epithelial cells from the peritoneal lining to mesenchymal cells leading to a formation of a thick membrane. The clinical features range from abdominal pain due to altered gut motility to frank features suggestive of intestinal obstruction. Making a pre-operative diagnosis is the biggest challenge in abdominal cocoon. However computerized tomography provides enough information to arrive at a diagnosis. Surgical intervention continues to remain the final option in an unremitting intestinal obstruction despite the role of conservative therapy using drugs proposed for treatment. The focus of management is early diagnosis and treatment in order to halt the progression to a frank cocoon. The paper reviews the etiopathogenesis and management of this intricate condition.