Cocoon abdomen: bowels in a web

Abstract

Cocoon abdomen is a rare, idiopathic condition characterised by fibrous encapsulation of the bowel segments giving an appearance of a cocoon. The patient may present with variable and non-specific symptoms like abdominal pain, tenderness, vomiting and it sometimes even leads to intestinal obstruction. We hereby report a case of 54-year-old male who presented with symptoms of intestinal obstruction. Apart from the sparing of 60 mm of the resection margin at either ends, most of the segment was encased by the peritoneum giving a ‘spider-web’ appearance. On opening the intestinal segment, there were multiple areas of kinking of the wall with narrowing of the lumen in the areas of the ‘cocooning’. No obvious mass lesion was identified either on the mucosal aspect or in the mesentery. Microscopic examination revealed that multiple loops of small bowel were tethered together by a loose, oedematous fibrovascular membrane. Sclerosing encapsulating peritonitis (SEP) is an extremely rare clinical entity and was first described by Foo et al. in 1978,1 in an adolescent girl, which is reported to be the most common age group. Our case was found in a middle-aged male, which differs in both age group and sex of the common incidence of this entity. The aetiology of this condition remains unknown; however there have been cases where the patients have had a prior abdominal surgery, abdominal tuberculosis, liver transplant or recurrent peritonitis.2 1.Foo KT, Ng KC, Rauff A, et al. Unusual small intestinal obstruction in adolescent girls: The abdominal cocoon. Br J Surg 1978; 65: 427–30.2.Stanley MM, Reyes CV, Greenlee HB, et al. Peritoneal fibrosis in cirrhotics treated with peritoneovenous shunting for ascites. Digest Dis Sci 1996; 41: 571–7.