Abstract
IntroductionSclerosing peritonitis or abdominal cocoon syndrome is characterized by small bowel loops completely encapsulated by a fibrocollagenous membrane in the center of the abdomen. Although cocooning of the abdomen is mostly seen in patients on peritoneal dialysis, it can occur de novo; it very rarely manifests as complete mechanical bowel obstruction.Case presentationA 46-year-old Asian man presented with complete mechanical bowel obstruction. He had previous attacks of partial bowel obstruction during the past 6 to 8 months, which was misdiagnosed as abdominal tuberculosis because tuberculosis is very prevalent in the region in which he lives. He took anti-tuberculosis therapy for 3 months but this did not result in resolution of his symptoms. This time he had diagnostic laparoscopy followed by laparotomy in which a fibrocollagenous membrane, resulting in entrapment of his bowel, was excised and his entire small bowel was freed.Postoperatively he again had a mild episode of partial bowel obstruction but this was relieved with a short course of steroids.DiscussionSclerosing peritonitis is a rare benign etiology of complete mechanical bowel obstruction. Patients might have suffered recurrent attacks of partial bowel obstruction in the past that were falsely managed on lines of other conditions such as tuberculosis, especially in endemic areas like Pakistan or India.ConclusionSclerosing peritonitis is a rare benign diagnosis which can manifest as complete bowel obstruction and a high index of suspicion is required to diagnose it. Contrast-enhanced computed tomography of the abdomen is a useful radiological tool to aid in preoperative diagnosis. Diagnostic laparoscopy is usually confirmatory.Peritoneal sac excision and adhesiolysis is the treatment and a short course of steroids in relapsing symptoms.
Highlights
Sclerosing peritonitis or abdominal cocoon syndrome is characterized by small bowel loops completely encapsulated by a fibrocollagenous membrane in the center of the abdomen
Sclerosing peritonitis is a rare benign diagnosis which can manifest as complete bowel obstruction and a high index of suspicion is required to diagnose it
Contrast-enhanced computed tomography of the abdomen is a useful radiological tool to aid in preoperative diagnosis
Summary
Sclerosing encapsulating peritonitis was first described more than a century ago and was initially termed peritonitis chronica fibrosa incapsulata to describe the membrane encasing the intestine; it has since been named ‘icing sugar’, fibroplastic peritonitis, and cocoon abdomen. CT findings of a membrane enveloping loops of small bowel were seen in some paraduodenal hernias, abdominal cocoon, and in peritoneal encapsulation. Differential diagnosis includes peritoneal encapsulation, which was described as a developmental anomaly where the whole of the small bowel is encased in a thin accessory membrane. The clinical symptoms of this condition differ from those of abdominal cocoon syndrome, in that the patients are mostly asymptomatic and the findings are incidental and late in life. Treatment, as in this case, is excision of membrane and releasing loops of bowel [7, 13]. A short course of steroids may be helpful in relapsing cases because of the inflammatory nature of this condition; evidence of use of steroids in cases of sclerosing peritonitis needs to be established
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