58 year old gentleman with longstanding Diabetes Mellitus , presented with history of abdominal pain and vomiting for 4 days . He was having recurrent episodes of pain in abdomen and vomiting for last 4 years. On abdominal examination he was having vague mass in periumbilical region . He was evaluated as a case of high gut obstruction . All lab investigations were normal . ECG and ECHO reports were normal . 320 slice CECT abdomen showed abdominal cocoon / idiopathic sclerosing peritonitis .
Abdominal cocoon syndrome is a rare entity that is also known in the literature as sclerosing peritonitis or sclerosing encapsulating peritonitis. For patients who are on chronic ambulatory peritoneal dialysis (CAPD), there is a loss of ultrafiltration capacity and a bloody dialysis effluent. However, early clinical features of sclerosing peritonitis are generally nonspecific and are frequently not recognized until the patient develops partial or complete small bowel obstruction.Peritoneal encapsulation may have a similar appearance to abdominal cocoon on radiologic studies. This is a congenital condition in which all or part of the small bowel is encased by an accessory peritoneal membrane. Usually, this is asymptomatic, but has been reported to cause bowel obstruction in a few cases. Pathologically, the encasing membrane is normal peritoneum rather than the thick fibrous-collagenous tissue seen in abdominal cocoon. Treatment is needed on the base of patient symptoms. I treated only two cases of primary symptomatic sclerosing peritonitis doing an adhesiolysis only
If I understood the question correctly, it is the rarest and most difficult condition known as well as 'the hostile abdomen' and 'Der Panzerbauch'. Both the mesothelial lining and abdominal cavity are absent replaced with the dense scar tissue. The intestinal wall becomes athrophic and very thin with a high probability of iatrogenic injuries. An operation may last several hours, and its result may not impress much.
I ought to say thanks to Prof.Reddy for the question and would be obliged extremely to learn collegues' opinions of the rational strategy of this dangerous pathologic condition.
I entirely agree. It can be a real challenge! Could this cocoon be due to abdominal TB rather than a primary sclerosing variety or congenital variety considering that he is 58 years and has had symptoms only for 4 years? Could we get a peritoneal cytology by a careful attempt at diagnostic laparoscopy - I know it is risky and a bit adventurous, however if we can do it and get a TB positive result, medical management might solve the problem. Just a thought....
ِDear friend
in challenging with such cases, definitely I begin my approach with balloon enteroscopy and usually you could be able to release adhesions and small bowel partial obstruction.
Clear liquid diet, transition to pureed diet which is Gluten free, oat free, low grain diet. Protein in easy digestible forms @ 1gm/Kgm lean body weight. Slow transition to solid food. Must add B12 SQ or SL, 1mg/day for methyl donation at DNA to RNA to occur for cellular repair.
Thank you .
This was the third case I dealt with in 30 years . One was due to ventriculo- peritoneal shunt . As mentioned by Dr. Andrey it took few hours ,and promptly reformed in a months time , and to my surprize to exactly as before . Then I removed the VP Shunt and released the cocoon again . He is well without any abdominal symptoms .( secondary sclerosing peritonitis ) .
The other two cases peritoneal biopsy showed only fibrosis and the bacteriology test were normal suggesting primary sclerosing peritonitis .
I felt that insertion of veress needle or by open technique is dangerous in these cases as there is no space unless it is an incomplete cocoon .
This patient was already managed conservatively several times for the similar episodes of pain .
I am not sure about the role of enteroscopy in these cases .
I have not had any similar cases sofar.i think after R/O of tb and malignancy open ahesionlysis woulld be prefered.
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