Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 14  |  Issue : 3  |  Page : 139-141
Abdominal cocoon secondary to tuberculosis


Yash Diagnostic Center, Yash Hospital and Research Center, Civil Lines, Kanth Road, Moradabad - 244 001, Uttar Pradesh, India

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   Abstract 

Abdominal cocoon or sclerosing encapsulating peritonitis is a rare cause of intestinal obstruction that has been described mostly in young adolescent girls. Thick fibrotic peritoneum encasing the small bowel in a small volume is a pathognomonic feature. This condition presents many difficulties in preoperative diagnosis. Early diagnosis can result in proper management, and may prevent the need for bowel resection. The author reports a case of a male patient with intermittent subacute intestinal obstruction and an abdominal cocoon encasing the small bowel secondary to abdominal tuberculosis, which was suspected preoperatively by radiology. To the best of our knowledge, this case represents one of the very few male patients with this disease entity reported in medical literature.

Keywords: Cocoon, intestinal obstruction, peritoneum, tuberculosis

How to cite this article:
Rastogi R. Abdominal cocoon secondary to tuberculosis. Saudi J Gastroenterol 2008;14:139-41

How to cite this URL:
Rastogi R. Abdominal cocoon secondary to tuberculosis. Saudi J Gastroenterol [serial online] 2008 [cited 2019 Aug 17];14:139-41. Available from: http://www.saudijgastro.com/text.asp?2008/14/3/139/41733


Abdominal cocoon is a rare acquired condition involving encapsulation of the small bowel by a fibrous membrane. Although well documented, the exact etiology is often unclear. The present report describes a case wherein the tubercle bacillus was identified as the etiological agent. The clinical, pathological and radiological features of this unusual disease are discussed.


   Case History Top


A 30-year-old man presented with complaints of vomiting and abdominal pain lasting a few days. He had several similar episodes in the past with spontaneous symptomatic relief. The patient had no previous history of practolol use, hepatic disease, abdominal surgery, peritoneal dialysis, ventriculoperitoneal and peritoneovenous shunting. Additionally, no clinical features of connective tissue disease or sarcoidosis could be identified. A family history of chest tuberculosis was, however, positive. Clinical examination revealed mildly distended abdomen. Laboratory studies were unremarkable.

Plain radiograph of the abdomen in supine posture revealed mildly dilated small bowel loops in the mid-abdominal region. Plain radiograph of the chest revealed fibrocalcific changes in the upper lobe of the right lung.

Abdominal ultrasonography revealed clustering of the small bowel loops in the mid-abdominal region. Mild interloop ascites was also noted. Few enlarged lymph nodes were seen in the small bowel mesentery.

Contrast-enhanced computed tomography (CT) of the abdomen was performed. It revealed clustered small bowel loops encapsulated within a thick membrane-like sac in the mid-abdomen [Figure 1] and [Figure 2] with dilated stomach and duodenum. Small amount of interloop ascites was also evident. Lymphadenopathy was noted in the small bowel mesentery and in the gastrohepatic ligament.

Based on the above findings, abdominal cocoon secondary to tuberculosis was suspected.

Exploratory laparotomy was performed few days later. At surgery, considerable length of the jejunum and ileum was found encased in a whitish, thickened membrane, which was resected. Lymphadenopathy was noted in the small bowel mesentery.

Histology of the membrane revealed fibrosis without inflammation, and nodal microscopy revealed features of tuberculosis.

Based on the clinical, radiological, surgical and histopathological findings, a diagnosis of abdominal cocoon secondary to abdominal tuberculosis was made. Postoperatively, the patient was initiated on anti-tuberculous treatment for 9 months. During 1 year of postoperative follow-up period, the patient remained asymptomatic.


   Discussion Top


There are numerous causes of intestinal obstruction. Kochhar et al . reported external hernias, volvulus, tuberculosis and post-operative or inflammatory adhesions as the most common causes of intestinal obstruction in India. [1]

Intestinal obstruction secondary to abdominal cocoon or peritonitis chronica fibrosa incapsulata is an infrequent clinical entity. Foo et al . first applied the term "abdominal cocoon" in 1978. [2]

Sclerosing encapsulating peritonitis (SEP) is an acquired condition. Prior abdominal surgery or peritonitis, chronic ambulatory peritoneal dialysis and prolonged use of practolol are the main causative factors. [3] Other conditions such as history of ventriculoperitoneal and peritoneovenous shunts, sarcoidosis, cirrhosis, systemic lupus erythematosus, propranolol therapy for constrictive pericarditis, fibroid uterus, endometrioma or tumor of ovary, and recurrent peritonitis have also been implicated. [4] Abdominal cocoon is a variant of SEP in which the small bowel is partly or completely encased in a thick, fibrous membrane. [5] The disease is commoner in the tropical and subtropical regions, and occurs mainly in young females. Postulated etiology of retrograde menstruation coupled with viral infection does not explain the occurrence in males. Although Foo et al . postulated tubercle bacilli as an etiology agent, no organisms were isolated in majority of the previously reported cases. [2]

The patient may present with signs and symptoms of acute, subacute or chronic intestinal obstruction, abdominal distension, weight loss or a mobile abdominal mass. The classic barium finding, described by Sieck et al ., is a serpentine or concertina-like configuration of dilated small bowel loops in a fixed U-shaped cluster or a "cauliflower sign," but these are not always present [5],[6] and are nonspecific. Delayed transit is more diagnostic.

Characteristic sonographic findings include altered peristalsis, adherence of the bowel to the anterior abdominal wall, intraperitoneal echogenic strands and membrane formation during the late stages of the disease.

CT is an important diagnostic tool, but few have reported CT findings of abdominal cocoon. [3],[7]

A typical finding of abdominal cocoon on CT is a concentration of a part of or the entire small bowel in the center of the abdomen encased by a soft tissue-density mantle. [7] Other CT features that may be seen include signs of obstruction, fixed and adherent intestinal loops, bowel wall thickening, localized fluid collections, peritoneal thickening and enhancement, calcification in peritoneum or bowel wall, and reactive adenopathy. [3] Ascites is an uncommon feature.

Prior to the era of CT imaging, definitive diagnosis was usually made during surgery. [5] The thickened membrane may be adherent to the surrounding structures. Within the cocoon, there may be interloop adhesions or adhesions between loops and the capsule. Extensive bowel resection is associated with high morbidity. Symptomatic relief generally ensues following conservative surgery, although recurrence has been reported. [5],[6]

Histopathological examination of the encapsulating membrane persistently shows thickened vascular fibrocollagenous tissue, with or without chronic inflammatory reaction evidenced by lymphocytic and plasma cell infiltrates. Mesenteric lymph nodes may demonstrate nonspecific reactive hyperplasia and may reveal the etiology.

Kaushik et al . [4] had reported six cases of abdominal cocoon secondary to tuberculosis, where the diagnosis was made during surgery since these cases presented with acute intestinal obstruction. In these cases, they were able to demonstrate caseating epithelioid cell granulomas in the membrane, although acid-fast bacilli could not be demonstrated. However, in our report, we were able to suspect the diagnosis preoperatively based on CT abdomen findings, allowing for surgical intervention that helped in early definitive diagnosis, thus improving the prognosis.

 
   References Top

1.Kochhar KS, Rai H, Singh H. The management of acute intestinal obstruction: A critical review of 238 cases. Indian J Surg 1966;28:553-64.  Back to cited text no. 1    
2.Foo KT, Ng KC, Rauff A, Foong WC, Sinniah R. Unusual small intestinal obstruction in girls: The abdominal cocoon. Br J Surg 1978;65:427-30.  Back to cited text no. 2  [PUBMED]  
3.Krestin GP, Kacl G, Hauser M, Keusch G, Burger HR, Hoffmann R. Imaging diagnosis of sclerosing peritonitis and relation of radiologic signs to the extent of disease. Abdom Imaging 1995;20:414-20.  Back to cited text no. 3  [PUBMED]  
4.Kaushik R, Punia RP, Mohan H, Attri AK. Tuberculous abdominal cocoon: A report of 6 cases and review of the Literature. World J Emerg Surg 2006;1:18.  Back to cited text no. 4    
5.Sieck JO, Cowgill R, Larkworthy W. Peritoneal encapsulation and abdominal cocoon: Case reports and a review of the literature. Gastroenterology 1983;84:1597-601.  Back to cited text no. 5  [PUBMED]  
6.Sahoo SP, Gangopadhyay AN, Gupta DK, Gopal SC, Sharma SP, Dash RN. Abdominal cocoon in children: A report of four cases. J Pediatr Surg 1996;31:987-8.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Wig JD, Gupta SK. Computed tomography in abdominal cocoon. J Clin Gastroenterol 1998;27:259-60.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Rajul Rastogi
C-002, Upkari Apartments, Plot no 9, Sector 12, Dwarka, Delhi - 110 078
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.41733

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    Figures

  [Figure 1], [Figure 2]

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