Acute presentation of cocoon abdomen as septic peritonitis mimicking with strangulated internal herniation: a case report

Background Abdominal cocoon syndrome is a rare cause of intestinal obstruction in which loops of small bowel get entrapped inside a fibro-collagenous membrane. Condition is also known in the literature as sclerosing peritonitis and in the majority of cases, it has no known cause. Although the majority of patients exhibit long-standing signs and symptoms of partial bowel obstruction in an out-patient clinic, its acute presentation in the emergency room with features of sepsis is extremely rare. This case report aims to describe the emergency presentation of cocoon abdomen with septic peritonitis. Case presentation A 35-year-old male with no known co-morbidity and no prior history of prior laparotomy presented in emergency room first time with a 1-day history of generalized abdomen pain, vomiting, and absolute constipation. He was in grade III shock and had metabolic acidosis. The clinical impression was of the perforated appendix, but initial contrast-enhanced computed tomography (CECT) was suggestive of strangulated internal herniation of small bowel. Emergency laparotomy after resuscitation revealed hypoperfused, but viable loops of small bowel entrapped in the sclerosing membrane. Extensive adhesiolysis and removal of the membrane were performed and the entire bowel was straightened. Postoperatively he remained well and discharged as planned. Histopathology report confirms features of sclerosing peritonitis. Discussion Cocoon abdomen is a very rare cause of acute small bowel obstruction presenting in an emergency with features of septic peritonitis. Condition is mostly chronic and generally mimics abdominal TB in endemic areas like India and Pakistan. A high index of suspicion is required in an emergency setting and exploratory laparotomy is diagnostic and therapeutic as well and the condition mimics internal herniation in acute cases. Conclusion Cocoon abdomen as a cause of septic peritonitis is extremely rare and might be an unexpected finding at laparotomy. Removal of membrane and estimation of the viability of entrapped bowel loops is the treatment of choice, which may require resection in the extreme case of gangrene.

Abdominal cocoon: precipitated by laparoscopic gas insufflation

A young male in his early 30s presented to us with increasing swelling at the umbilicus, and an umbilical hernia was diagnosed. At laparoscopic intraperitoneal onlay mesh (IPOM) repair, an unexpected finding of a thin innocuous-looking fibrous film over the small bowel was noted. This finding presented a dilemma as to the probable pathology of this material, and a decision had to be made on whether laparoscopic IPOM could be continued. It was prudently decided to abandon the plan of placing a mesh intraperitoneally and an open repair of the umbilical hernia was done. In retrospect this was a wise decision, as, after 7 months he had to have a laparotomy for intestinal obstruction, when the classic thick fibrous encapsulating abdominal cocoon was seen. Hence here we have followed the evolution of the abdominal cocoon from its original asymptomatic phase to the classic encapsulating sclerosing peritonitis with probably laparoscopic gas insufflation being the precipitating factor.

Non Typhoidal Salmonella Suppuration of Ovarian Cyst with Sclerosing Peritonitis: An old disease, A New Face

Invasive non-typhoidal Salmonella is an emerging problem in developing regions like Africa and Asia. Infection of ovarian cysts by typhoid bacilli is a complication dating to the 1800s and is rare in the postantibiotic era. A diabetic, hypertensive post-menopausal lady, our patient presented with a large paraovarian cyst infected the Salmonella group B bacillus. The infection is likely transmitted hematogenously or by the surrounding adherent bowel and omentum. Interestingly, our patient developed sclerosing peritonitis and osseous metaplasia of the rectus sheath as well, possibly a peritoneal inflammation to a disseminated infection. Compounded by her diabetes, the ossified rectus healed poorly, leading to burst abdomen in the post-operative period. Hence, our patient presented with a rare manifestation of an emerging disease. A depressed immune status, influenced by her comorbidities, and the lack of sanitation in pockets of South Asia may have led to a reappearance of these once historic complications of typhoid.

Sclerosing peritonitis presenting as complete mechanical bowel obstruction: a case report

Introduction Sclerosing 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 presentation A 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. Discussion Sclerosing 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. Conclusion 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. Diagnostic laparoscopy is usually confirmatory. Peritoneal sac excision and adhesiolysis is the treatment and a short course of steroids in relapsing symptoms.