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Apollo Medicine 2012 SeptemberVolume 9, Number 3; pp. 249e251 Case Report

Ovarian cyst and abdominal cocoon syndrome

P. Lakshmi Reddy*, Satyamvada Pandey

Depar*CorreReceivCopyrihttp://d

ABSTRACT

The abdominal cocoon syndrome is described as a rare entity in which part or whole of the small bowel is enclosed ina fibrous membrane. This case report is of a 35 years old woman who had a provisional diagnosis of ovarian cyst.Intraoperatively she was found to have abdominal cocoon syndrome. Laparotomy with cystectomy was done. Shedeveloped subacute intestinal obstruction 5 days later. This was managed conservatively.

Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.

Keywords: Abdomen, Ovarian cyst, Cocoon, Sclerosing encapsulating peritonitis

CASE REPORT

A 35-year-old lady was admitted with a right ovarian cystand left hydrosalpinx on routine health check up. She wasplanned for a diagnostic laparoscopy. She gave a historyof irritable bowel syndrome since 5 years. She had nobladder, bowel complaints at presentation. There was nohistory of acute pain abdomen or menstrual complaints orof other medical illnesses or any surgeries earlier.

Patient was clinically stable. Local examination of theabdomen revealed a soft abdomen with normal bowelsounds and minimal tenderness in the right iliac fossa.There was no guarding or rigidity and no organomegaly.Pelvic examination was deferred as she was unmarried.

Routine laboratory work up was within normal limits.Ultrasound of abdomen showed a bulky uterus witha 9 cm right ovarian cyst with no septa or internal echoes.Left hydrosalpinx was 6 cm in size.

Under a provisional clinical diagnosis of right ovariancyst with left hydrosalpinx, a diagnostic laparoscopy wasplanned. Laparoscopy had to be abandoned because pneu-moperitoneum could not be created; the parietal peritoneumwas seen loosely adherent to bowel and omentum likea flimsy membrane. Laparotomy was done and confirmedthe same. A diagnosis of cocoon syndrome was made.

tment of Obstetrics and Gynecology, Apollo Hospitals, Jubilee Hills, Hsponding author. email: plmmreddy@yahoo.comed: 31.5.2012; Accepted: 30.6.2012; Available online: 7.7.2012ght � 2012, Indraprastha Medical Corporation Ltd. All rights reservedx.doi.org/10.1016/j.apme.2012.06.011

There was a thin walled cyst about 12 cm in diametercovered by bowel by thin adhesions. Blood stained fluidwas drained and sent for cytology. Cyst wall was excisedand sent for histopathological examination. Right ovarywas seen at the base of the cyst and looked normal. Right

yderabad, India.

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250 Apollo Medicine 2012 September; Vol. 9, No. 3 Reddy and Pandey

tube was dilated. Retort shaped left hydrosalpinx wasnoted. Left salpingectomy was done and tube sent for histo-pathological examination. Left ovary was buried underadhesions and could not be visualized. Reports revealedbenign cystic lesion with no significant abnormality. AFBstaining yielded negative results.

Her postoperative period was uneventful and she wasdischarged from the hospital on the 3rd postoperative day.

Patient again presented to emergency room 2 days afterdischarge with frequent vomiting. She also gave a historyof nausea and acidity, and occasional mild spasmodicpain since last 2 days. There were no urinary symptoms,hematemesis, blood in stools, fever, constipation or loosemotions. She gave a history of similar episodes twice inchildhood in winter months and was then managedconservatively.

Physical examination revealed no signs of dehydration.Vitals were stable. Abdomen was soft with mild tenderness,mild gaseous distension and no organomegaly. Bowelsounds were sluggish. X-ray erect abdomen showedmultiple air fluid levels in small bowel suggestive of smallbowel obstruction. USG abdomen was done and revealeddilated small bowel loops with food particles and sluggishparticles, suggestive of subacute intestinal obstruction.She was reviewed by a surgeon and a diagnosis of subacuteintestinal obstruction was confirmed.

She was managed conservatively with intravenousfluids, kept nil by mouth, daily serum electrolytes weremonitored and replaced as required. She was continuedon antispasmodics, antacids and strict intake output was

charted. Total parenteral nutrition had to be started on the6th day of hospital stay. She gradually improved with novomiting and was able to pass flatus. She tolerated clearliquids from 8th day, and semisolid diet from 10th day.She received dietary advice from a dietician.

She was discharged on the 10th day and was advised toavoid dairy products. She has been on regular follow-upsfor the last 4 months and has been free of bowel symptomsthroughout this period.

DISCUSSION

Abdominal cocoon is a rare condition. It has been describedin literature as sclerosing encapsulating peritonitis.1 It ischaracterized by partial or complete encasement of smallbowel by a thick ring of fibrous tissue and adhesions result-ing in clumping of bowel loops.

The condition usually affects adolescent girls rangingfrom 6 to 18 years, mostly in tropical regions.2 The exactetiology is still not clear.

The condition has been classified as primary (idiopathic)and secondary when it has a definite cause. Foo et al re-ported this condition in 10 young girls 2 years aftermenarche. They presented with bowel obstruction probablycaused by chemical peritonitis due to retrograde menstrua-tion.3 Several other hypotheses suggest retrograde perito-nitis via fallopian tube and damage by cell mediatedimmunity incited by pelvic infection as causes.

Secondary causes include placement of peritoneovenousshunts for refractory ascites, continuous ambulatory perito-neal dialysis, systemic lupus erythematosus and use ofpovidone iodine for abdominal wash and beta-adrenergicblocker, practolol.4e7

Clinically patients report with features of recurrent acuteor chronic small bowel obstruction due to compression ofintestines within the constricting cocoon.3,4,8 An abdominalmass may also be seen due to encapsulated and dilatedsmall bowel loops.

Preoperative diagnosis is rarely made. Laboratory andradiological studies are nonspecific, they may suggest intes-tinal obstruction. Ultrasound is usually inconclusive, orshows only a vague clump of bowel loops with relativefixity and echogenic peritoneal membrane. Preoperativebarium meal showed characteristic serpentine configurationof dilated small bowel loops within the cocoon.8

Using CT, a preoperative diagnosis of abdominal cocoonis more likely. Imaging features are, however not pathogno-monic.9 CECT would reveal congregated small gut loopsconfined to a single area and encased in a thick membranewith a dilated proximal small intestine and gradual narrow-ing of the distal ileum with obstruction.10

Abdominal cocoon syndrome Case Report 251

The final diagnosis of abdominal cocoon is usuallybased on intraoperative and histopathology findings.11

The characteristic finding is the encasement of whole orpart of small bowel by a thick shiny membrane, aptly simu-lating a cocoon. Small bowel loops are stuck together byflimsy adhesions separated easily by blunt or sharpdissection.12

Surgery is the cornerstone in the management of abdom-inal cocoon. It includes careful dissection and excision ofthick sac around small bowel. Resection of bowel is indi-cated only if it is non-viable.13 Some studies suggest inci-dental appendectomy as the appendix would be difficultto find in the future in case of acute appendicitis. Prognosisof abdominal cocoon after surgery seems excellent and norecurrence has been described.14

CONCLUSION

This case report describes an unusual presentation ofovarian cyst and hydrosalpinx with abdominal cocoonsyndrome. It aims at raising awareness about this syndrometo enable earlier preoperative diagnosis and prevent unnec-essary bowel resection. It also mentions the role of conser-vative nonsurgical treatment in selected cases of intestinalobstruction with cocoon syndrome as in this case and theneed of further studies to critically analyze it.

CONFLICTS OF INTEREST

All authors have none to declare.

REFERENCES

1. Owtschinnikow PJ. Peritonitis chronica fibrosa incapsulata.Arch Klin Chir. 1907;83:623e634.

2. Attar ZB, Nazir Z, Moazam F. The abdominal cocoon e anunusual cause of intestinal obstruction in adolescents. AnnTrop Paediatr. 1993;13:99e102.

3. Foo KT, Ng KC, Rauff A, Foong WC, Sinmah R. Unusualsmall intestinal obstruction in adolescent girls: the abdominalcocoon. Br J Radiol. 1978;65:427e430.

4. Sieck JO, Cowgill R, Larkuothy W. Peritoneal encapsulationand abdominal cocoon: case reports and a review of the liter-ature. Gastroenterology. 1983;84:1597e1601.

5. Kazuyoshi O, Yoshihiko O, Toshinori O, et al. Sclerosingencapsulating peritonitis: regional changes of peritoneum.Nephron. 2002;92:481e483.

6. Keating JP, Neill M, Hill GL. Sclerosing encapsulating perito-nitis after intraperitoneal use of povidone iodine. Aust N Z JSurg. 1997;67:742e744.

7. Brown P, Baddeley H, Read AE, Davis JD, Mcgarry J. Scle-rosing peritonitis, an unusual reaction to a beta-adrenergic-blocking drug (practolol). Lancet. 1974;2:1477e1481.

8. Cambria RP, Shamberger RC. Small bowel obstruction causedby the abdominal cocoon syndrome: possible association withLeVeen shunt. Surgery. 1984;95:501e503.

9. Ranganathan S, Abdullah BJJ, Sivanesaratnam V. Abdominalcocoon syndrome. J HK Coll Radiol. 2003;6:201e203.

10. Mohanty D, Jain BK, Agrawal J, Gupta A, Agrawal V. Abdom-inal cocoon: clinical presentation, diagnosis, and management.J Gastrointest Surg. 2009 Jun;13(6):1160e1162. Epub 2008Jul 23.

11. Kumar M, Deb M, Parshad R. Abdominal cocoon: report ofa case. Surg Today. 2000;30:950e953.

12. Yip FW, Lee SH. The abdominal cocoon. Aust N Z J Surg.1992;62:638e642.

13. Kumar M, Deb M, Parshad R. Abdominal cocoon: report ofa case. Surg Today. 2000;30:950e953. http://dx.doi.org/10.1007/s005950070053.

14. Foo KT, Ng KC, Rauff A, Foong WC, Sinniah R. Unusualsmall intestinal obstruction in adolescent girls: the abdominalcocoon. Br J Surg. 1978;65:427e430.

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