Computed tomography features of small intestinal obstruction caused by primary abdominal cocoon

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Objective To summarize the computed tomography (CT) features of small intestinal obstruction caused by primary abdominal cocoon and investigate the essentials of diagnosis and differential diagnosis. Methods The retrospective descriptive study was adopted. The clinical data of 1 patient with small intestinal obstruction caused by primary abdominal cocoon who was admitted to the Second Affiliated Hospital of Jiaxing University on October 6, 2014 were collected. The patient underwent abdominal CT on admission and at 10 hours after admission. The patient received emergency exploratory laparotomy after preoperative preparation, and then postoperative regular symptomatic treatment and pathological examination. Results of abdominal CT were observed, including imaging features of abdominal masses, extent of small intestinal obstruction, situation of intestinal tube within the masses, vessel distribution in the mesentery and fibrous capsules around the mesentery. Situation of operation, routine blood test, biochemical indicator, blood coagulation indexes, postoperative recovery, complications, results of pathological examination and situation of patient during follow-up were recorded. The follow-up by telephone interview and outpatient examination was applied to the patient till October 31, 2015, including detecting the dietary, with or without symptoms of abdominal pain and distension, haematemesis and hematochezia, routine blood retest, liver function, renal function and CT. Results Results of abdominal CT on admission: (1) coronal plain scan of abdominal CT showed that there were signs of incomplete intestinal obstruction, and local small intestinal dilatation and gas accumulation in left abdominal region without specific sign. (2) Plain scan of abdominal CT showed that there were the coated with thickened fibrous capsules around the intestinal tube, banana shape with agglomerate and expanding-distortion intestinal tube and aggregative, stretching and twisting mesentery with abnormal vessel distribution. (3) Sagittal reconstruction images of abdominal CT showed that a huge mass consisted of fibrous capsules as cocoon and agglomerate and expanding-distortion intestinal tube was petal-like and fixed on posterior abdominal wall. (4) Coronal reconstruction images of abdominal CT showed that agglomerate and expanding-distortion intestinal tube was annularly surrounded by uneven thickness fibrous capsules with abnormal vessel distribution in the mesentery. Results of abdominal CT at 10 hours after admission: (1) coronal plain scan of abdominal CT showed that small intestinal obstruction was obviously exacerbated and expanding intestinal tubes were increased and aggravated. (2) Plain scan of abdominal CT showed that a typical sign of small intestinal obstruction was exacerbated and there were multiple air-fluid levels in the agglomerate and expanding-distortion intestinal tube with fluid and gas accumulation. Patient underwent successful enterodialysis+ resection of fibrous capsules. During operation, a huge mass in the intestine from suspensory ligament of duodenum to ileocecum was fixed on posterior abdominal wall and surrounded by dense, smooth and white fibrous capsules, partial colon was also surrounded by fibrous capsules and greater omentum was missing. Patient received the postoperative supporting treatments of fasting, anti-infection and inhibition of acid. Number of white blood cells, absolute value and percentage of neutrophils, levels of high-sensitivity C-reactive protein and procalcitonin were 17.10×109/L, 15.70×109/L, 91.5%, 127.49 mg/L and 1.370 μg/L by blood routine retest at postoperative day 1, respectively. Patient had normal liver, renal and coagulation functions. Fluid diet intake at postoperative week 1 was gradually replaced by normal diet intake. Patient had normal liver and renal functions by blood routine retest at postoperative day 10 and a good recovery without intestinal fistula, abdominal and pulmonary infections and other complications. Postoperative pathological examination showed that gross specimen was mainly composed of cocoon-shaped, grayish white and tough fibrous capsules. Fibrous capsules were consisted of proliferative fibrofatty tissues by microscope observation, with small vascular hyperplasia and large numbers of the inflammatory cell infiltration. Patient was diagnosed with small intestinal obstruction caused by primary abdominal cocoon after operation, and followed up for 1 year with normal diet intake and without abdominal pain and distension, nausea and vomiting, melena and discomfort. There was normal blood routine retest, liver and renal functions and distribution of the intestine in abdomen by CT examination. No dilatation of the intestinal tube was found and strip-like high density shadow in ileocecum was detected and considered as remnant fibrous capsules. Conclusion Imaging features of small intestinal obstruction caused by primary abdominal cocoon include agglomerate and expanding-distortion intestinal tube fixed on abdomen, partial intestinal tubes dilatation, intestinal fluid accumulation and air-fluid level, aggregative, stretching and twisting mesentery with abnormal vessel distribution, thickened fibrous capsules around intestinal loops and among intestinal tubes. Key words: Abdominal cocoon; Intestinal obstruction; Tomography