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Year : 2012  |  Volume : 55  |  Issue : 3  |  Page : 379-380
Abdominal cocoon: Case report of a rare cause of intestinal obstruction

1 Department of Pathology, JJM Medical College, Davangere, Karnataka, India
2 Department of Pathology, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India

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Date of Web Publication29-Sep-2012


Abdominal cocoon or sclerosing encapsulated peritonitis is a rare cause of intestinal obstruction often seen in adolescent girls. We present a case of an abdominal cocoon in a 14-year-old female presenting as a surgical emergency. The patient underwent excision of the involved segment of small bowel along with a part of ascending colon. Gross morphology revealed intestinal coils wrapped within a thick fibrous membrane. Diagnosis of this condition is seldom possible on radiological imaging. Characteristic gross appearance is showcased in our case, to create more awareness of this finding.

Keywords: Abdominal cocoon, intestinal obstruction, sclerosing encapsulated peritonitis

How to cite this article:
Chatura RK, Nayak VJ. Abdominal cocoon: Case report of a rare cause of intestinal obstruction. Indian J Pathol Microbiol 2012;55:379-80

How to cite this URL:
Chatura RK, Nayak VJ. Abdominal cocoon: Case report of a rare cause of intestinal obstruction. Indian J Pathol Microbiol [serial online] 2012 [cited 2022 Jul 7];55:379-80. Available from: https://www.ijpmonline.org/text.asp?2012/55/3/379/101751

   Introduction Top

Adhesions, strictures and hernias are the common causes of intestinal obstruction, a common surgical emergency. Abdominal cocoon is a very rare cause of intestinal obstruction, with fewer than 70 cases reported in literature and seldom with histopathological confirmation. [1],[2]

   Case Report Top

A 14-year-old girl presented with complaints of intermittent colicky abdominal pain. On examination, a firm, irregular, nontender, deep-seated mass, was felt per abdomen. No mass could be localized on abdominal ultrasound scanning, but multiple irregular echogenic structures were observed in the lower abdomen with occasional peristalsis.

Emergency exploratory laparotomy revealed distal small bowel encased in a thick membrane. The membrane was adherent to the intestines, but separate from the parietal peritoneum which was not thickened. The membrane was left undisturbed suspecting it to be of tuberculous etiology. The encapsulated portion of the bowel was excised, along with the appendix and a portion of ascending colon which appeared to be uninvolved.

Gross examination of the excised specimen showed the small intestinal portion completely encased by a grayish white membrane stopping short of the ileocecal junction. The membrane was 2-mm thick and could be easily separated from the intestines. Underlying intestines were slightly edematous and in tight coils arranged in concertina fashion bound to each other by a thin, shiny membrane [Figure 1]. On microscopy the membrane showed hyalinized collagen and few blood vessels [Figure 2]. The ileum showed edema in the lamina propria. Appendix and colon were unremarkable. Lymph nodes showed sinus histiocytosis, but no granulomas were visualized in any of the sections studied.
Figure 1: Abdominal cocoon with opened membrane showing intestinalcoils, Inset: fl imsy adhesions between the loops of intestine

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Figure 2: Small intestine with the adherent thick fi brous membrane. (Hematoxylin and eosin, × 10)

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   Discussion Top

Abdominal cocoon or sclerosing encapsulating peritonitis is a condition characterized by total or partial encasement of the small bowel by a fibrocollagenous cocoon like sac. It was first described and named by Foo et al.[1] in 1978.

The condition has been classified as primary and secondary, based on whether it is idiopathic or has a definite cause. [2] Although several hypotheses have been proposed, the etiology of the primary form remains uncertain. Foo et al. [1] grouped this condition for the first time. They described 10 cases all of which were seen in young girls, within 2 years of onset of menarche and with no previous history of abdominal surgeries or beta adrenergic blocker intake. They concluded by postulating that retrograde menstruation with subclinical viral peritonitis was the causative factor in cases studied. [1] The argument has not been refuted till date.

Secondary causes have included placement of Le veen shunts, continuous ambulatory peritoneal dialysis, systemic lupus erythematosus, tuberculosis, use of povidone iodine washout and beta adrenergic blockers. [3],[4],[5],[6]

Notable clinical features are its occurrence in a relatively young girl without an obvious cause of intestinal obstruction, a history of similar episodes that resolved spontaneously, a presentation with abdominal pain and vomiting and the presence of a non-tender soft mass on abdominal palpation. Our patient had all the above features except vomiting. The features were similar to those described by Foo et al. [1] for primary abdominal cocoon syndrome.

Preoperative diagnosis of abdominal cocoon by computerized tomography (CT) has been reported in a few case reports. [7] The CT findings are however not pathognomonic and many cases are diagnosed during emergency exploratory laparotomy performed for obstructive symptoms. [8]

Resecting the membrane intraoperatively has been shown to unravel the tightly coiled intestines thus relieving the obstruction.­[1],[7] The tight coiling of the intestine is described as being akin to concertina coils. Most patients register an uneventful recovery following surgery. However, in peritoneal encapsulation resulting out of tuberculous aetiology, postoperative complications such as enterocutaneous fistulae requiring re-exploration have been reported. Furthermore, recovery in these patients is slower.­[4] In our case, tuberculosis was suspected intraoperatively and hence ileocolectomy was performed. Postoperative period was uneventful with no complications having been reported till date.

Histology of the membranes often consists of fibrocollagenous tissue with non specific inflammatory component. [1],[7],[8] Our case showed a thick membrane in close approximation with the muscle layer. Caseating epithelioid granulomas have been found in the membranes of tuberculous etiology. In our case granulomas were found neither in the membrane nor in the resected bowel segment.

   Conclusions Top

In cases of intestinal obstruction presenting as a surgical emergency in adolescent females the diagnosis of abdominal cocoon must be kept in mind. Preoperative diagnosis is seldom possible by radiological imaging alone. Characteristic gross appearance is showcased in our case, to create more awareness of this rare entity.

   References Top

1.Foo KT, Ng KC, Rauff A, Foong WC, Sinmah R. Unusual small intestinal obstruction in adolescent girls: The abdominal cocoon. Br J Surg 1978;65:427-30.  Back to cited text no. 1
2.Deeb LS, Mourad F, El-Zein Y, Uthman S. Abdominal cocoon in a man: Preoperative diagnosis and literature review. J Clin Gastroenterol 1998;26:148-50.  Back to cited text no. 2
3.Stanley MM, Reyes CV, Greenly HB, Nemchausky B, Reinhardt F. Peritoneal fibrosis in cirrhotic treated with peritoneovenous shunting for ascites: An autopsy study with clinical correlation. Dig Dis Sci 1996;41:571-7.  Back to cited text no. 3
4.Kaushik R, Punia RP, Mohan H, Attri A. Tuberculous abdominal cocoon - a report of 6 cases and review of literature. World J Emerg Surg 2006;1:18.  Back to cited text no. 4
5.Keating JP, Neill M, Hill GL. Sclerosing encapsulating peritonitis after intraperitonealuse of povidone iodine. Aust NZ J Surg 1997;67:742-4.  Back to cited text no. 5
6.Brown P, Baddeley H, Read AE, Davis JD, Mcgarry J. Sclerosing peritonitis, an unusual reaction to a beta-adrenergic-blocking drug (practolol). Lancet 1974;2:1477-81.  Back to cited text no. 6
7.Gupta S, Shirahatti RG, Anand J. CT findings in abdominal cocoon. AJR Am J Roentgenol 2004;183:1658-60.  Back to cited text no. 7
8.Devay AO, Gomceli I, Korukluoglu B, Kusdemir A. An unusual and difficult diagnosis of intestinal obstruction: The abdominal cocoon. Case report and review of literature. World J Emerg Surg 2008;3:36.  Back to cited text no. 8

Correspondence Address:
Vaibhav J Nayak
#3638/1, 9TH main, 7TH cross, MCC B Block, Davangere, Karnataka - 577 004
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.101751

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