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Intestinal obstruction due to abdominal cocoon: CT findings
European Journal of Radiology Extra 70 (2009) e79–e81
Contents lists available at ScienceDirect
European Journal of Radiology Extra journal homepage: intl.elsevierhealth.com/journals/ejrex
Intestinal obstruction due to abdominal cocoon: CT findings Neslihan Tas¸delen a,∗ , Alp Demira˘g b , Murat Kalaycı b , Bengi Gürses a , Nuri Özgür Kılıc¸kesmez a , Nil C¸omuno˘glu c , Ahmet Nevzat Gürmen a a
Yeditepe University Hospital, Department of Radiology, Istanbul, Turkey Yeditepe University Hospital, Department of General Surgery, Istanbul, Turkey c Yeditepe University Hospital, Department of Pathology, Istanbul, Turkey b
a r t i c l e
i n f o
Article history: Received 10 July 2008 Received in revised form 23 October 2008 Accepted 1 December 2008 Keywords: Abdominal cocoon Computed tomography
a b s t r a c t Abdominal cocoon is a relatively rare cause of intestinal obstruction. We report the oldest patient in the literature which is diagnosed as abdominal cocoon with typical computed tomography (CT) and intraoperative findings. CT showed conglomerated intestinal loops showing mild dilatation at the center of the abdomen which is encased with a membrane represented by a thickened peritoneum. © 2008 Elsevier Ireland Ltd. All rights reserved.
The abdominal cocoon, which is also known as idiopathic form of sclerosing encapsulating peritonitis is a relatively rare cause of intestinal obstruction. It is characterized by total or partial fibrotic encapsulation of the bowel. Most cases are diagnosed incidentally at laparotomy [1–5]. It is mostly seen in peritoneal dialysis patients [6]. We herein report an old female patient presenting with computed tomography (CT) findings of an abdominal cocoon who is the oldest patient in the literature, to our knowledge. 1. Case report An 85-year-old woman admitted to the emergency room with epigastric pain, constipation and bilious vomiting over a duration of 3 days. She had no history of similar complaints, previous surgery or trauma but chronic constipation for the last 50 years. Physical examination showed a marked abdominal distension with rebound tenderness, and increased bowel sounds in pitch and frequency. Physical examination also showed that a rounded shaped mass located in the left mid-abdomen. She was in distress, but afebrile and haemodynamically stable. The laboratory findings showed abnormal values for white blood cells 14580/ with left shifted, Hgb 10.6 g/dl [(11.7–16.1), Hct 32.3 % (35–47), C-reactive protein 17.5 mg/l (normal range <6),
∗ Corresponding author at: Yeditepe University Hospital, Department of Radiology, Devlet Yolu Ankara Cad. No: 102-104, 34752 Kozyata˘gı, Istanbul, Turkey. Tel.: +90 216 5784371; fax: +90 216 5784950. E-mail address: [email protected] (N. Tas¸delen). 1571-4675/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2008.12.001
serum potassium 3.1 mmol/l (3.7–5.4), and serum albumin 2.6 g/dl (3.4–4.8). There was neither air-fluid levels nor free intraperitoneal air on plain abdominal radiographs obtained with the patient standing (Fig. 1). After a period of follow-up, as there is no relief of abdominal pain and distension, CT scans were obtained. Contrast-enhanced CT of the abdomen showed conglomerate of jejunal and ileal loops showing mild dilatation at the center of the abdomen which is covered with a membrane (Fig. 2). Mild fluid among the loops was also remarkable (Fig. 2). There was no intestinal wall thickening. The patient underwent an emergency laparotomy under a diagnosis of a strangulated intestinal obstruction. Intraoperatively, a cocoon-like white thickened peritoneum was seen encasing small intestine loops from the duodenal–jejunal flexure to the terminal ileum with the presence of interloop adhesions and haemoserous ascites. A pouch was cut open and the membrane was composed of a fibrous peel. A part of the small intestine showed necrotic change and 140 cm the necrotic bowel was removed with the total removal of the membrane and jejunoileostomy was performed. Histopathological examination showed the membrane to consist of fibrin and a few inflammatory cells (Fig. 3). The postoperative course was uneventful, and the patient was discharged 1 week after the operation. A diagnosis abdominal cocoon was established after review of the literature based on intraoperative and CT findings. 2. Discussion Sclerosing encapsulating peritonitis (SEP) is a rare condition which is characterized by a thick fibrotic membrane encasing the
e80
N. Tas¸delen et al. / European Journal of Radiology Extra 70 (2009) e79–e81
Fig. 3. Fibrinous membrane and few inflammatory cells. (H&Ex400).
Fig. 1. Plain abdominal radiograph in standing position revealed no air-fluid levels and free intraperitoneal air.
small bowel loops. It was first described by Owtschinnikow in 1907 as “peritonitis chronica fibrosa incapsulata” and has been named in various forms in the literature [1–5]. The term “abdominal cocoon” was used first by Foo et al. in 1978 [7]. SEP can be classified as idiopathic or secondary. The secondary form has been reported in association with peritoneal dialysis [6]. Other rare causes include abdominal tuberculosis, betablocker intake, ventriculoperitoneal and peritoneovenous shunts, orthotopic transplantation. The idiopathic form is also known as
Fig. 2. Sequential images of contrast-enhanced abdominal CT showed dilated intestinal loops congregated at the center of the abdomen, which is encased with a thickened peritoneum (arrowhead) with peritoneal fluid (arrow) among bowel loops.
N. Tas¸delen et al. / European Journal of Radiology Extra 70 (2009) e79–e81
abdominal cocoon has been classically described in young adolescent females from the tropical and subtropical countries. The etiology of this entity has remained relatively unknown. The hypotheses theorized as a possible etiology, such as retrograde menstruation with viral infection, retrograde peritonitis incited by gynecological infection, history of prior abdominal surgery or active biliary tract inflammation causing peritoneal inflammation does not explain the entity in whole cases [1,2,8]. One of the major differential diagnosis is peritoneal tuberculosis especially the dry type. It is characterized by mesenteric thickening, fibrous adhesions and caseous nodules. Omentum appears to be smudged, caked or thickened. Peritoneal thickening with enhancement may be seen [9]. In our patient also the etiology is unclear. There was no finding of tuberculosis or history of gynecological infection, abdominal surgery or beta-blocker intake. Peritoneal encapsulation is a rare developmental malformation of the intestine, in which the encapsulation of the bowel loop occurs by a transparent membrane. The membrane consists of a regular peritoneal layer of mesothelial cells with chronic inflammatory reaction [2,6,10]. Clinical presentation include acute, subacute or chronic intestinal obstruction, weight loss, nausea and sometimes abdominal mass [1,2]. On barium studies, conglomerated intestinal loops forming a cauliflower appearance is seen [1]. Sonography may show localized dilated intestinal loops and sometimes may be useful in demonstrating the fibrous sac [11]. CT is the method of choice in the diagnosis of abdominal cocoon. As described also in our patient, intestinal loops congregated to the center of the abdomen, also surrounded with thickened membrane is the typical appearance of abdominal cocoon. But that surrounding membrane may be thin and difficult to identify on CT images [8]. Careful examination of conglomerated intestinal loops on CT may be helpful. In chronic SEP patients especially in peritoneal dialysis patients may show additional features such as loculated fluid collections, peritoneal calcification, tethering of the small bowel and thickening of the abdominal wall [1,6,8]. Magnetic resonance imaging (MRI) can also be used in subacute or chronic intestinal obstruction which may demonstrate findings similar to CT like clustering of loops surrounded by a thick membrane [5] or focal intestinal wall thickening [12]. Differential diagnosis of abdominal cocoon especially forming acute signs of intestinal obstruction should include especially inter-
e81
nal hernia, peritoneal tuberculosis and bowel infarction. Adhesive band also is another diagnosis which should be thought in patients with the history of previous surgery. However, definitive transitional zone and markedly dilated proximal intestinal loops is not so severe in abdominal cocoon [4]. In this case there was no bowel wall thickening which may be useful in the diagnosis of bowel infarction. In internal hernia, there is no thickened peritoneal membrane around the dilated intestinal loops. Although the existence of the peritoneal membrane surrounding the fluid and intestinal loops is diagnostic for abdominal cocoon, the membrane may not be seen due to the fluid collection or thin appearance. Peritoneal tuberculosis especially dry type may demonstrate peritoneal or mesenteric thickening mostly associated with thickening of bowel loops, dense adhesions and caseous nodules [9] which does not exist in our patient. In conclusion, abdominal cocoon is a rare entity which may show difficulty in preoperative diagnosis. However a high index of clinical suspicion with typical CT findings may facilitate the diagnosis even in the lack of possible etiologies. References [1] Lalloo S, Krishna D, Maharajh J. Case report: abdominal cocoon associated with tuberculous pelvic inflammatory disease. Br J Radiol 2002;75(890):174–6. [2] Xu P, Chen LH, Li YM. Idiopathic sclerosing encapsulating peritonitis (or abdominal cocoon): a report of 5 cases. World J Gastroenterol 2007;13(26):3649– 51. [3] Santos VM, Barbosa Jr ER, Lima SH, Porto AS. Abdominal cocoon associated with endometriosis. Singapore Med J 2007;48(9):e240–2. [4] Kim MY, Koo JH, Yeon JW, Suh CH, Kim KK. Ileal obstruction caused by idiopathic sclerosing encapsulating peritonitis. Abdom Imaging 1999;24(1):82–4. [5] Menassa-Moussa L, Bleibel L, Sader-Ghorra C, Smayra T, Aoun NJ. MRI findings in intestinal cocoon. AJR Am J Roentgenol 2006;186(3):905–6. [6] George C, Al-Zwae K, Nair S, Cast JE. Computed tomography appearances of sclerosing encapsulating peritonitis. Clin Radiol 2007;62(8):732–7. [7] Foo KT, Ng KC, Rauff A, Foong WC, Sinniah R. Unusual small intestinal obstruction in adolescent girls: the abdominal cocoon. Br J Surg 1978;65(6):427– 30. [8] Gupta S, Shirahatti RG, Anand J. CT findings of an abdominal cocoon. AJR Am J Roentgenol 2004;183(6):1658–60. [9] Burrill J, Williams CJ, Bain G, Conder G, Hine AL, Misra RR. Tuberculosis: a radiologic review. Radiographics 2007;27(5):1255–73. [10] Okamoto N, Maeda K, Fujisaki M, Sato H. Abdominal cocoon in an aged man: report of a case. Surg Today 2007;37(3):258–60. [11] Rokade ML, Ruparel M, Agrawal JB. Abdominal cocoon. J Clin Ultrasound 2007;35(4):204–6. [12] Hüser N, Stangl M, Lutz J, Fend F, Kreymann B, Gaa J. Sclerosing encapsulating peritonitis: MRI diagnosis. Eur Radiol 2006;16(1):238–9.
Contents lists available at ScienceDirect
European Journal of Radiology Extra journal homepage: intl.elsevierhealth.com/journals/ejrex
Intestinal obstruction due to abdominal cocoon: CT findings Neslihan Tas¸delen a,∗ , Alp Demira˘g b , Murat Kalaycı b , Bengi Gürses a , Nuri Özgür Kılıc¸kesmez a , Nil C¸omuno˘glu c , Ahmet Nevzat Gürmen a a
Yeditepe University Hospital, Department of Radiology, Istanbul, Turkey Yeditepe University Hospital, Department of General Surgery, Istanbul, Turkey c Yeditepe University Hospital, Department of Pathology, Istanbul, Turkey b
a r t i c l e
i n f o
Article history: Received 10 July 2008 Received in revised form 23 October 2008 Accepted 1 December 2008 Keywords: Abdominal cocoon Computed tomography
a b s t r a c t Abdominal cocoon is a relatively rare cause of intestinal obstruction. We report the oldest patient in the literature which is diagnosed as abdominal cocoon with typical computed tomography (CT) and intraoperative findings. CT showed conglomerated intestinal loops showing mild dilatation at the center of the abdomen which is encased with a membrane represented by a thickened peritoneum. © 2008 Elsevier Ireland Ltd. All rights reserved.
The abdominal cocoon, which is also known as idiopathic form of sclerosing encapsulating peritonitis is a relatively rare cause of intestinal obstruction. It is characterized by total or partial fibrotic encapsulation of the bowel. Most cases are diagnosed incidentally at laparotomy [1–5]. It is mostly seen in peritoneal dialysis patients [6]. We herein report an old female patient presenting with computed tomography (CT) findings of an abdominal cocoon who is the oldest patient in the literature, to our knowledge. 1. Case report An 85-year-old woman admitted to the emergency room with epigastric pain, constipation and bilious vomiting over a duration of 3 days. She had no history of similar complaints, previous surgery or trauma but chronic constipation for the last 50 years. Physical examination showed a marked abdominal distension with rebound tenderness, and increased bowel sounds in pitch and frequency. Physical examination also showed that a rounded shaped mass located in the left mid-abdomen. She was in distress, but afebrile and haemodynamically stable. The laboratory findings showed abnormal values for white blood cells 14580/ with left shifted, Hgb 10.6 g/dl [(11.7–16.1), Hct 32.3 % (35–47), C-reactive protein 17.5 mg/l (normal range <6),
∗ Corresponding author at: Yeditepe University Hospital, Department of Radiology, Devlet Yolu Ankara Cad. No: 102-104, 34752 Kozyata˘gı, Istanbul, Turkey. Tel.: +90 216 5784371; fax: +90 216 5784950. E-mail address: [email protected] (N. Tas¸delen). 1571-4675/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2008.12.001
serum potassium 3.1 mmol/l (3.7–5.4), and serum albumin 2.6 g/dl (3.4–4.8). There was neither air-fluid levels nor free intraperitoneal air on plain abdominal radiographs obtained with the patient standing (Fig. 1). After a period of follow-up, as there is no relief of abdominal pain and distension, CT scans were obtained. Contrast-enhanced CT of the abdomen showed conglomerate of jejunal and ileal loops showing mild dilatation at the center of the abdomen which is covered with a membrane (Fig. 2). Mild fluid among the loops was also remarkable (Fig. 2). There was no intestinal wall thickening. The patient underwent an emergency laparotomy under a diagnosis of a strangulated intestinal obstruction. Intraoperatively, a cocoon-like white thickened peritoneum was seen encasing small intestine loops from the duodenal–jejunal flexure to the terminal ileum with the presence of interloop adhesions and haemoserous ascites. A pouch was cut open and the membrane was composed of a fibrous peel. A part of the small intestine showed necrotic change and 140 cm the necrotic bowel was removed with the total removal of the membrane and jejunoileostomy was performed. Histopathological examination showed the membrane to consist of fibrin and a few inflammatory cells (Fig. 3). The postoperative course was uneventful, and the patient was discharged 1 week after the operation. A diagnosis abdominal cocoon was established after review of the literature based on intraoperative and CT findings. 2. Discussion Sclerosing encapsulating peritonitis (SEP) is a rare condition which is characterized by a thick fibrotic membrane encasing the
e80
N. Tas¸delen et al. / European Journal of Radiology Extra 70 (2009) e79–e81
Fig. 3. Fibrinous membrane and few inflammatory cells. (H&Ex400).
Fig. 1. Plain abdominal radiograph in standing position revealed no air-fluid levels and free intraperitoneal air.
small bowel loops. It was first described by Owtschinnikow in 1907 as “peritonitis chronica fibrosa incapsulata” and has been named in various forms in the literature [1–5]. The term “abdominal cocoon” was used first by Foo et al. in 1978 [7]. SEP can be classified as idiopathic or secondary. The secondary form has been reported in association with peritoneal dialysis [6]. Other rare causes include abdominal tuberculosis, betablocker intake, ventriculoperitoneal and peritoneovenous shunts, orthotopic transplantation. The idiopathic form is also known as
Fig. 2. Sequential images of contrast-enhanced abdominal CT showed dilated intestinal loops congregated at the center of the abdomen, which is encased with a thickened peritoneum (arrowhead) with peritoneal fluid (arrow) among bowel loops.
N. Tas¸delen et al. / European Journal of Radiology Extra 70 (2009) e79–e81
abdominal cocoon has been classically described in young adolescent females from the tropical and subtropical countries. The etiology of this entity has remained relatively unknown. The hypotheses theorized as a possible etiology, such as retrograde menstruation with viral infection, retrograde peritonitis incited by gynecological infection, history of prior abdominal surgery or active biliary tract inflammation causing peritoneal inflammation does not explain the entity in whole cases [1,2,8]. One of the major differential diagnosis is peritoneal tuberculosis especially the dry type. It is characterized by mesenteric thickening, fibrous adhesions and caseous nodules. Omentum appears to be smudged, caked or thickened. Peritoneal thickening with enhancement may be seen [9]. In our patient also the etiology is unclear. There was no finding of tuberculosis or history of gynecological infection, abdominal surgery or beta-blocker intake. Peritoneal encapsulation is a rare developmental malformation of the intestine, in which the encapsulation of the bowel loop occurs by a transparent membrane. The membrane consists of a regular peritoneal layer of mesothelial cells with chronic inflammatory reaction [2,6,10]. Clinical presentation include acute, subacute or chronic intestinal obstruction, weight loss, nausea and sometimes abdominal mass [1,2]. On barium studies, conglomerated intestinal loops forming a cauliflower appearance is seen [1]. Sonography may show localized dilated intestinal loops and sometimes may be useful in demonstrating the fibrous sac [11]. CT is the method of choice in the diagnosis of abdominal cocoon. As described also in our patient, intestinal loops congregated to the center of the abdomen, also surrounded with thickened membrane is the typical appearance of abdominal cocoon. But that surrounding membrane may be thin and difficult to identify on CT images [8]. Careful examination of conglomerated intestinal loops on CT may be helpful. In chronic SEP patients especially in peritoneal dialysis patients may show additional features such as loculated fluid collections, peritoneal calcification, tethering of the small bowel and thickening of the abdominal wall [1,6,8]. Magnetic resonance imaging (MRI) can also be used in subacute or chronic intestinal obstruction which may demonstrate findings similar to CT like clustering of loops surrounded by a thick membrane [5] or focal intestinal wall thickening [12]. Differential diagnosis of abdominal cocoon especially forming acute signs of intestinal obstruction should include especially inter-
e81
nal hernia, peritoneal tuberculosis and bowel infarction. Adhesive band also is another diagnosis which should be thought in patients with the history of previous surgery. However, definitive transitional zone and markedly dilated proximal intestinal loops is not so severe in abdominal cocoon [4]. In this case there was no bowel wall thickening which may be useful in the diagnosis of bowel infarction. In internal hernia, there is no thickened peritoneal membrane around the dilated intestinal loops. Although the existence of the peritoneal membrane surrounding the fluid and intestinal loops is diagnostic for abdominal cocoon, the membrane may not be seen due to the fluid collection or thin appearance. Peritoneal tuberculosis especially dry type may demonstrate peritoneal or mesenteric thickening mostly associated with thickening of bowel loops, dense adhesions and caseous nodules [9] which does not exist in our patient. In conclusion, abdominal cocoon is a rare entity which may show difficulty in preoperative diagnosis. However a high index of clinical suspicion with typical CT findings may facilitate the diagnosis even in the lack of possible etiologies. References [1] Lalloo S, Krishna D, Maharajh J. Case report: abdominal cocoon associated with tuberculous pelvic inflammatory disease. Br J Radiol 2002;75(890):174–6. [2] Xu P, Chen LH, Li YM. Idiopathic sclerosing encapsulating peritonitis (or abdominal cocoon): a report of 5 cases. World J Gastroenterol 2007;13(26):3649– 51. [3] Santos VM, Barbosa Jr ER, Lima SH, Porto AS. Abdominal cocoon associated with endometriosis. Singapore Med J 2007;48(9):e240–2. [4] Kim MY, Koo JH, Yeon JW, Suh CH, Kim KK. Ileal obstruction caused by idiopathic sclerosing encapsulating peritonitis. Abdom Imaging 1999;24(1):82–4. [5] Menassa-Moussa L, Bleibel L, Sader-Ghorra C, Smayra T, Aoun NJ. MRI findings in intestinal cocoon. AJR Am J Roentgenol 2006;186(3):905–6. [6] George C, Al-Zwae K, Nair S, Cast JE. Computed tomography appearances of sclerosing encapsulating peritonitis. Clin Radiol 2007;62(8):732–7. [7] Foo KT, Ng KC, Rauff A, Foong WC, Sinniah R. Unusual small intestinal obstruction in adolescent girls: the abdominal cocoon. Br J Surg 1978;65(6):427– 30. [8] Gupta S, Shirahatti RG, Anand J. CT findings of an abdominal cocoon. AJR Am J Roentgenol 2004;183(6):1658–60. [9] Burrill J, Williams CJ, Bain G, Conder G, Hine AL, Misra RR. Tuberculosis: a radiologic review. Radiographics 2007;27(5):1255–73. [10] Okamoto N, Maeda K, Fujisaki M, Sato H. Abdominal cocoon in an aged man: report of a case. Surg Today 2007;37(3):258–60. [11] Rokade ML, Ruparel M, Agrawal JB. Abdominal cocoon. J Clin Ultrasound 2007;35(4):204–6. [12] Hüser N, Stangl M, Lutz J, Fend F, Kreymann B, Gaa J. Sclerosing encapsulating peritonitis: MRI diagnosis. Eur Radiol 2006;16(1):238–9.