Abdominal cocoon syndrome-a rare culprit behind small bowel ischemia and obstruction: Three case reports

Abstract

BACKGROUND

Abdominal cocoon syndrome (ACS) represents a category within sclerosing encapsulating peritonitis, characterized by the encapsulation of internal organs with a fibrous, cocoon-like membrane of unknown origin, resulting in bowel obstruction and ischemia. Diagnosing this condition before surgery poses a challenge, often requiring confirmation during laparotomy. In this context, we depict three instances of ACS: One linked to intestinal obstruction, the second exclusively manifesting as intestinal ischemia without any obstruction, and the final case involving a discrepancy between the radiologist and the surgeon.

CASE SUMMARY

Three male patients, aged 53, 58, and 61 originating from Northern Thailand, arrived at our medical facility complaining of abdominal pain without any prior surgeries. Their vital signs remained stable during the assessment. The diagnosis of abdominal cocoon was confirmed through abdominal computed tomography (CT) before surgery. In the first case, the CT scan revealed capsules around the small bowel loops, showing no enhancement, along with mesenteric congestion affecting both small and large bowel loops, without a clear obstruction. The second case showed intestinal obstruction due to an encapsulated capsule on the CT scan. In the final case, a patient presented with recurring abdominal pain. Initially, the radiologist suspected enteritis as the cause after the CT scan. However, a detailed review led the surgeon to suspect encapsulating peritoneal sclerosis (ACS) and subsequently perform surgery. The surgical procedure involved complete removal of the encapsulating structure, resection of a portion of the small bowel, and end-to-end anastomosis. No complications occurred during surgery, and the patients had a smooth recovery after surgery, eventually discharged in good health. The histopathological examination of the fibrous membrane (cocoon) across all cases consistently revealed the presence of fibro-collagenous tissue, without any indications of malignancy.

CONCLUSION

Individuals diagnosed with abdominal cocoons commonly manifest vague symptoms of abdominal discomfort. An elevated degree of clinical suspicion, combined with the application of appropriate radiological evaluations, markedly improves the probability of identifying the abdominal cocoon before surgical intervention. In cases of complete bowel obstruction or ischemia, the established norm is the comprehensive removal of the peritoneal sac as part of standard care. Resection with intestinal anastomosis is advised solely when ischemia and gangrene have been confirmed.

Keywords: Sclerosing encapsulation peritonitis, Abdominal cocoon, Peritoneal Fibrosis, Peritoneal encapsulation syndrome, Intestinal obstruction, Surgery, Case report

Core Tip: Diagnosing Abdominal cocoon syndrome (ACS) poses challenges, often necessitating laparotomy for confirmation. This study presents three distinct ACS cases: one featuring bowel obstruction, another with isolated ischemia, and the last highlighting disparities between radiological findings and surgical assessments. Preoperative computed tomography scans played a crucial role in diagnosis, revealing diverse manifestations such as capsules encasing the bowels, mesenteric congestion, or ambiguous obstructions. Surgical excision of encapsulating structures led to successful recovery. Additionally, one case involved a traumatic event, requiring exploratory laparotomy a year later, where no fibrosis was found around the previously removed intestine. Early clinical suspicion, coupled with precise radiological examination, aids in identifying ACS before surgery. Complete removal of the sac during obstruction/ischemia is the established approach, recommending resection solely for confirmed ischemic complications.