IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 7, July 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(7):345–348.www.ijcasereportsandimages.com

Abdominal cocoon: A rare cause of intestinal obstructionM R Madan Karthik Raj

ABSTRACTIntroduction: Abdominal cocoon syndrome isdescribed as rare condition causing intestinalobstruction where a part or whole small bowel isencased in a fibrous membrane. Case Report:This case report is of a 30­year­old male patientwho had undergone laparoscopic appendectomyfive months ago presented with history, clinicaland radiological findings suggestive of intestinalobstruction. He had been having similarepisodes of intestinal obstruction which getsresolved spontaneously before and aftersurgery. Peroperatively inner aspect of entireperitoneal cavity was lined by a membranewhich was adherent in certain areas causingobstruction. Adhesiolysis was done and patientrecovered well. Conclusion: Awareness of thisrare condition along with early diagnosis withradiological guidance and surgical interventionreduces morbidity of the patient.Keywords: Intestinal obstruction, Abdominalcocoon

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Raj MRMK. Abdominal cocoon: A rare cause ofintestinal obstruction. International Journal of CaseReports and Images 2013;4(7):345–348.*********

doi:10.5348/ijcri­2013­07­328­2

INTRODUCTIONAbdominal cocoon is a rare condition that refers to atotal or partial encapsulation of the small bowel by afibrocollagenous membrane or cocoon with localinflammatory reaction which leads to acute or chronicbowel obstruction. This was first described byOwtschinnikow in 1907 [1] as ‘Peritonitis chronicfibrosa incapsulata’ and as ‘sclerosing encapsulatingperitonitis’ by Deeb et al. [2] in 1998. Abdominal cocoonusually presents as acute or recurrent sub acuteintestinal obstruction with or without mass. Diagnosisof abdominal cocoon is usually made per operativelyand surgical removal of obstruction causing membranegives complete recovery. The aim of this report is todescribe a young man with abdominal cocoon and toalert physicians to the diagnosis and management ofthis condition.

CASE REPORTA 30­year­old male presented with vague complainsof intermittent abdominal pain and back pain, nausea,vomiting and abdominal distension. He had undergonelaparoscopic appendectomy five months ago. He hadbeen having similar complaints before and after thesurgery. No records about the operative findings in theprevious surgery were available with the patient. Onexamination, his abdomen was distended withgeneralized tenderness in all quadrants. No free fluid inthe abdomen made out on clinical examination. Nomass or hernia was present in port sites. On

CASE REPORT OPEN ACCESS

M R Madan Karthik Raj1

Affi l iations: 1MS, Assistant Professor, Department ofGeneral Surgery, Vinayaka Mission’s Kirupanandhavariyar Medical College and Hospital, Salem, Tamil Nadu,India.Corresponding Author: Dr. M R Madan Karthik Raj, MS(General Surgery), No 24 B, Shri saraswathi Apartments,Ramakrishna Road, Salem, Tamil Nadu, India; PostalCode: 636 007; Ph: 91 9894333979; E-mail :drmkraja@gmail .com

Received: 1 8 January 201 3Accepted: 1 0 May 201 3Published: 01 July 201 3

Raj et al. 345

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 7, July 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(7):345–348.www.ijcasereportsandimages.com Raj et al. 346

auscultation, bowel sounds were sluggish. Initially thediagnosis was suspected as adhesive obstruction andwas started on conservative management withoutsymptomatic relief even after 12 hours. Blood countswere within normal limits. Computed tomography (CT)scan of abdomen showed all small bowel loops exceptduodenum and distal ileal loops were encased within asac like structure with various thickness and smallbowel showed signs of obstruction but no radiologicalevidence of mesenteric ischemia and suggested it to be acase of internal hernia or abdominal cocoon (Figure 1).Radiologist suggested patient to be a case of internalhernia or abdominal cocoon causing intestinalobstruction. Since patient did not respond well forconservative management, he was taken up forlaparotomy. Per operatively thick membrane noted justafter opening up the parietal peritoneum which had tobe opened to visualize intestines. Inner aspect of entireperitoneal cavity, both parietal and visceral peritoneumwas covered with a membrane of variable thickness andin some places membrane was adherent causingintestinal obstruction (Figure 2). Membrane causingobstruction were released with sharp dissection (Figure3) and samples taken by peeling off the membrane fromsmall bowel for biopsy (Figure 4). Since entireperitoneal cavity was covered with membrane, it couldnot be totally removed (Figure 5). Postoperative periodwas uneventful. Histopathological examination of themembrane showed nonspecific inflammatory cells withfibrosis.

DISCUSSIONAbdominal cocoon, also referred to as sclerosingperitoneal encapsulation or sclerosing en­capsulating

peritonitis, is a rare cause of acute abdomen, mostlyinvolving young adolescent females. Abdominal cocoonmay be classified into primary or idiopathic andsecondary forms [3].

Figure 1: Computed tomography scan of abdomen. The arrowshows the membrane lining the peritoneum.

Figure 2: The appearance after opening the abdomen.Membrane covering the entire small bowel and area ofadhesion causing obstruction can be seen.

Figure 3: Release of adhesion by sharp dissection.

Figure 4: Peeling of the membrane covering the small bowel.

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 7, July 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(7):345–348.www.ijcasereportsandimages.com Raj et al. 347

The pathogenesis of this syndrome remainsunknown in primary type; however in secondaryvariant, etipathogenesis is co­related to congenitaldysplasia, chronic asymptomatic peritonitis, somemedicines (e.g., proctolol) continuous ambulatoryperitoneal dialysis. Although retrograde menstruationwith or without viral infection of the fallopian tubes hasbeen suggested as a possible etiology [3], it does notaccount for the occasional occurrence of abdominalcocoon in males [4] as in our case. The clinicalpresentation of the abdominal cocoon syndrome mostlyoccurs as acute or sub acute intestinal obstructionwhich, in most cases, requires surgical intervention.Preoperative diagnosis of the syndrome is usuallydifficult. There are four main clinical features suggestedin literature for preoperative diagnosis [5].These are as follows:(i) A relatively young female patient without anobvious cause of bowel obstruction.(ii) Past history of similar episodes withsymptomatic relief.(iii) Presentation with symptoms suggestive ofbowel obstruction but absence of cardinalsymptoms such as distention.(iv) Presence of soft non­tender abdominal mass.However in our patient, similar episodes of intestinalobstruction with spontaneous symptomatic relief andabdominal distension were present. And the definitivediagnosis is achieved only after laparotomy. Asdescribed in literature, typically, the appearance of coillike pattern of the small bowel with areas of adhesionand dense thick membrane covering small and largebowel was seen [6]. The treatment of choice isadhesiolysis or total removal of membrane.

CONCLUSIONAbdominal cocoon syndrome is rare and difficult todiagnose condition which requires better awareness ofthe condition and a combination of clinical examinationand radiologic studies may enhance chances ofpreoperative diagnosis. Early intervention and

Figure 5: The appearance at the end of adhesiolysis. There isstill membrane covering small bowel.

appropriate perioperative treatment can improve theoutcome of this rare condition.*********

Author ContributionsM R Madan Karthik Raj – Substantial contributions toconception and design, Acquisition of data, Analysis andinterpretation of data, Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be publishedGuarantorThe corresponding author is the guarantor ofsubmission.Conflict of InterestAuthors declare no conflict of interest.Copyright© M R Madan Karthik Raj 2013; This article isdistributed under the terms of Creative Commonsattribution 3.0 License which permits unrestricted use,distribution and reproduction in any means providedthe original authors and original publisher are properlycredited. (Please see www.ijcasereportsandimages.com/copyright­policy.php for more information.)

REFERENCES1. Owtschinnikow PJ. Peritonitis chronic fibrosaincapsulata. ArchKlin Chir 1907;83:623–4. (Citedby): Constantinides F, DiNunno N, Bernasconi P,Jonjic N, Melato M. A new type of peritonealencapsulation of the small bowel. Am J Surg Pathol1998 Oct;22(10):1297–8.2. Deeb LS, Mourad FH, El­Zein YR, Uthman SM.Abdominal cocoon in a man: preoperative diagnosisand literature review. J Clin Gastroenterol1998;26(2):148–50.3. Al­Abassi AA, Emad M. Abdominal cocoon. Anunusual cause of intestinal obstruction. Saudi Med J2004;25(10):1482–5.4. Lalloo S, Krishna D, Maharajh J. Case report:abdominal cocoon associated with tuberculouspelvic inflammatory disease. Br J Radiol2002;75(890):174–6.5. Yip FW, Lee SH. The abdominal cocoon. Aust N Z JSurg 1992;62(8):638–42.6. Sieck JO, Cowgill R, Larkworthy W. Peritonealencapsulation and abdominal cocoon. Case reportsand a review of the literature. Gastroenterology1983;84(6):1597–1601.

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 7, July 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(7):345–348.www.ijcasereportsandimages.com Raj et al. 348

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