Idiopathic sclerosing encapsulating peritonitis: Abdominal cocoon

Jenny N Tannoury, Bassam N Abboud, Department of General Surgery, Faculty of Medicine, Hotel Dieu de France Hospital, Saint-Joseph University, Beirut 16-6830, Lebanon.
World Journal of Gastroenterology (Impact Factor: 2.37). 05/2012; 18(17):1999-2004. DOI: 10.3748/wjg.v18.i17.1999
Source: PubMed
ABSTRACT
Abdominal cocoon, the idiopathic form of sclerosing encapsulating peritonitis, is a rare condition of unknown etiology that results in an intestinal obstruction due to total or partial encapsulation of the small bowel by a fibrocollagenous membrane. Preoperative diagnosis requires a high index of clinical suspicion. The early clinical features are nonspecific, are often not recognized and it is difficult to make a definite pre-operative diagnosis. Clinical suspicion may be generated by the recurrent episodes of small intestinal obstruction combined with relevant imaging findings and lack of other plausible etiologies. The radiological diagnosis of abdominal cocoon may now be confidently made on computed tomography scan. Surgery is important in the management of this disease. Careful dissection and excision of the thick sac with the release of the small intestine leads to complete recovery in the vast majority of cases.

Full-text

Available from: Bassam Abboud
EDITORIAL
Idiopathic sclerosing encapsulating peritonitis: Abdominal
cocoon
Jenny N Tannoury, Bassam N Abboud
Jenny N Tannoury, Bassam N Abboud,
Department of Gen-
eral Surgery, Faculty of Medicine, Hotel Dieu de France Hospi-
tal, Saint-Joseph University, Beirut 16-6830, Lebanon
Author contributions:
Abboud BN designed the research; Tan-
noury JN and Abboud BN performed the research; Tannoury JN
and Abboud BN analyzed the data; Tannoury JN and Abboud
BN wrote the paper.
Correspondence to: Bassam N Abboud, MD, Professor,
De-
partment of General Surgery, Faculty of Medicine, Hotel Dieu
de France Hospital, Saint-Joseph University, Alfred Naccache
Street, Beirut 16-6830, Lebanon. dbabboud@yahoo.fr
Telephone:
+961-1-615300
Fax:
+961-1-615295
Received:
November 21, 2011
Revised:
February 20, 2012
Accepted:
February 26, 2012
Published online:
May 7, 2012
Abstract
Abdominal cocoon, the idiopathic form of sclerosing
encapsulating peritonitis, is a rare condition of unknown
etiology that results in an intestinal obstruction due to
total or partial encapsulation of the small bowel by a
brocollagenous membrane. Preoperative diagnosis re-
quires a high index of clinical suspicion. The early clinical
features are nonspecic, are often not recognized and
it is difcult to make a denite pre-operative diagnosis.
Clinical suspicion may be generated by the recurrent
episodes of small intestinal obstruction combined with
relevant imaging ndings and lack of other plausible eti-
ologies. The radiological diagnosis of abdominal cocoon
may now be condently made on computed tomogra-
phy scan. Surgery is important in the management of
this disease. Careful dissection and excision of the thick
sac with the release of the small intestine leads to com-
plete recovery in the vast majority of cases.
© 2012 Baishideng. All rights reserved.
Key words:
Peritonitis; Sclerosis; Encapsulate; Intesti-
nal obstruction; Computed tomography scan; Surgery
Peer reviewers: A Ibrahim Amin, MD, Department of Surgery,
Queen Margaret Hospital, Dunfermline, Fife KY12 0SU,
United Kingdom; Vincenzo Stanghellini, Professor, Internal
Medicine and Gastroenterology, University of Bologna, VIA
MASSARENTI 9, -40138 Bologna, Italy
Tannoury JN, Abboud BN. Idiopathic sclerosing encapsulating
peritonitis: Abdominal cocoon. World J Gastroenterol 2012;
18(17): 1999-2004 Available from: URL: http://www.wjgnet.
com/1007-9327/full/v18/i17/1999.htm DOI: http://dx.doi.
org/10.3748/wjg.v18.i17.1999
INTRODUCTION
Sclerosing encapsulating peritonitis (SEP) is a rare con-
dition of unknown etiology. It is characterized by a thick
grayish-white brotic membrane, partially or totally en-
casing the small bowel, and can extend to involve other
organs like the large intestine, liver and stomach. It was
rst observed by Owtschinnikow in 1907 and was called
peritonitis chronica fibrosa incapsulata
[1-5]
. SEP can be
classied as idiopathic or secondary. The idiopathic form
is also known as abdominal cocoon, was rst described
by Foo
et al
in 1978. Abdominal cocoon is a relatively
rare cause of intestinal obstruction
[6-21]
. Postoperative
adhesions account for about 60% of patients with small
bowel obstruction. Unusual cases are encountered in
only 6% of patients. Abdominal cocoon is one such
unusual case of small bowel obstruction
[9]
. Based on a
review of the literature (case series and case reports),
we discuss in this paper, etiology, clinical presentation,
radiological appearances, diagnosis, treatment, prognosis,
and histopathology of abdominal cocoon.
ETIOLOGY
The etiology of this entity has remained relatively un-
known. The abdominal cocoon has been classically
World J Gastroenterol 2012 May 7; 18(17): 1999-2004
ISSN 1007-9327 (print) ISSN 2219-2840 (online)
© 2012 Baishideng. All rights reserved.
Online Submissions: http://www.wjgnet.com/1007-9327ofce
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doi:10.3748/wjg.v18.i17.1999
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Tannoury J
et al
. Abdominal cocoon
described in young adolescent females from the tropical
and subtropical countries, but adult case reports from
temperate zones can be encountered in literature
[1,22-27]
.
To explain the etiology, a number of hypotheses have
been proposed. These include retrograde menstruation
with a superimposed viral infection, retrograde peritoni-
tis and cell-mediated immunological tissue damage incit-
ed by gynecological infection. However, since this condi-
tion has also been seen to affect males, premenopausal
females and children, there seems to be little support for
these theories
[1,24-28]
. Further hypotheses are therefore
needed to explain the cause of idiopathic SEP. Since ab-
dominal cocoon is often accompanied by other embryo-
logic abnormalities such as greater omentum hypoplasia,
and developmental abnormality may be a probable etiol-
ogy
[1]
. Greater omentum hypoplasia and mesenteric ves-
sel malformation was demonstrated in some cases. To
elucidate the precise etiology of idiopathic SEP, further
studies of cases are necessary.
The secondary form of SEP has been reported in
association with continuous ambulatory chronic perito-
neal dialysis (PD)
[29-38]
. SEP is a serious complication of
PD which leads to decrease ultraltration and ultimately
intestinal obstruction. For some authors
[37]
, the inci-
dence of SEP was 1.2%, but rose to 15% after 6 years,
and 38% after 9 years on PD. The risk of SEP is low
early in the course of PD, but increases progressively at
6 years and beyond. For others, the respective cumula-
tive incidences of peritoneal sclerosis at 3, 5 and 8 years
were 0.3%, 0.8% and 3.9%. This condition was inde-
pendently predicted by younger age and the duration of
PD, but not the rate of peritonitis
[33]
. Other rare causes
of secondary form of SEP
[39-52]
include, prior abdominal
surgery, subclinical primary viral peritonitis, recurrent
peritonitis, beta-blocker treatment (practolol), perito-
neovenous shunting, pertioneoventricular shunting and,
more rarely, abdominal tuberculosis, sarcoidosis, familial
Mediterranean fever, intraperitoneal chemotherapy, cir-
rhosis, liver transplantation, gastrointestinal malignancy,
luteinized ovarian thecomas, endometriosis, protein S
deciency, dermoid cyst rupture, and brogenic foreign
material.
CLINICAL PRESENTATION
Preoperative diagnosis requires a high index of clinical
suspicion. The early clinical features of SEP are nonspe-
cic and are often not recognized
[1-12]
. Clinically, it pres-
ents with recurrent abdominal pain, nausea, vomiting,
anorexia, weight loss, malnutrition, recurrent episodes
of acute, subacute or chronic small bowel incomplete or
complete obstruction, and at times with a palpable soft
non tender abdominal mass, but some patients may be
asymptomatic. In some cases, abdominal distension was
secondary to ascites. A high index of clinical suspicion
may be generated by the recurrent attacks of non-stran-
gulating obstruction in the same individual combined
with relevant imaging ndings and lack of other etiolo-
gies. The preoperative diagnosis of this entity may be
helpful for proper treatment of these patients
[2-5]
.
Less than 1% of PD patients develop overt SEP as
manifested by combinations of weight loss, ultrafiltra-
tion failure, and intestinal obstruction
[33-35]
.
Clinicians must rigorously pursue a preoperative di-
agnosis, as it may prevent a “surprise” upon laparotomy
and unnecessary procedures for the patient, such as
bowel resection. Although it is difcult to make a de-
nite preoperative diagnosis, most cases are diagnosed
incidentally at laparotomy. A better awareness of this
entity and the imaging techniques may facilitate pre-
operatively diagnosis
[1,6-9]
.
RADIOLOGY APPEARANCES
Conventional radiographs may show dilated bowel loops
and air uid level. Contrast study of the small intestine
in SEP shows varying lengths of small bowel tightly en-
closed in a “cocoon’’ of thickened peritoneum, proximal
small bowel dilatation, and increased transit time. It may
show a xed cluster of dilated small bowel loops lying
in a concertina like fashion, giving a cauliower-like ap-
pearance (“cauliower sign” )
[10,53]
.
Ultrasound ndings described in SEP include a tri-
laminar appearance of the bowel wall, tethering of the
bowel to the posterior abdominal wall, dilatation and x-
ation of small bowel loops, ascites, and membrane for-
mation. Ultrasonography may show a thick-walled mass
containing bowel loops, loculated ascites and fibrous
adhesions. Sonography shows the small bowel loops en-
cased in a thick membrane made best visible only in the
presence of ascites, and may show small bowel loops ar-
ranged in concertina shape with a narrow posterior base,
having overall appearance of cauliower
[10,53-55]
.
The radiological diagnosis of SEP may now be con-
dently made on computed tomography (CT) scan
[10,53-60]
.
CT of the abdomen may help in obtaining an early, reli-
able, and noninvasive diagnosis of SEP for which opti-
mal management can be planned (Figure 1A and B). CT
gives complete picture of the entity and associated com-
plications with exclusion of other causes of intestinal
obstruction. The exact diagnosis of this entity is made
by computed tomography of the abdomen demonstrat-
ing small bowel loops congregated to the center of
abdomen encased by a thick membrane
[58]
. CT features
of peritoneal calcication, peritoneal thickening, marked
enhancement of the peritoneum, loculated uid collec-
tions, gross ascites with small-bowel intestine loops con-
gregated in a single area in the peritoneal cavity, clustered
small-bowel loops encased by a thin membrane-like sac,
tethering or matting of the small bowel loops, thicken-
ing of the bowel wall, soft tissue density mantle, serosal
bowel wall calcication, and calcication over liver cap-
sule, spleen, posterior peritoneal wall may be diagnostic
of SEP in the appropriate clinical setting. Tethering or
matting of the small bowel is usually posterior to the
loculated uid collection, although bowel is sometimes
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seen to be oating within these collections
[57]
. Fibrosis
results in retraction of the root of the mesentery caus-
ing the bowel to clump together leading to obstruction
and dysfunction. Retraction of the mesentery can lead to
a characteristic appearance of the tethered small bowel
loops that we have dubbed the ‘‘gingerbread man’’ sign.
In some series, diagnosis of abdominal cocoon was
made by a combination of abdominal CT and clinical
presentations.
DIAGNOSIS
A high index of clinical suspicion may be generated by
the recurrent attacks of non-strangulating obstruction
in the same individual combined with relevant imaging
findings and lack of other etiologies. The preopera-
tive diagnosis of this entity may be helpful for proper
treatment of these patients. Most cases are diagnosed
incidentally at laparotomy, although a preoperative diag-
nosis is purported feasible by a combination of barium
follow-through (concertina pattern or cauliflower sign
and delayed transit of contrast medium), ultrasound, and
computed tomography of the abdomen (small bowel
loops congregated to the center of the abdomen encased
by a soft-tissue density mantle)
[3-5,61]
.
There are many causes of intestinal obstruction but
differential diagnosis of this condition is mainly from
internal hernias
[11]
, voluminous intussusception
[62]
, simple
localized peritoneal adhesions, and chronic idiopathic
intestinal pseudo-obstruction
[63]
. The main CT features
of an internal hernia are: (1) Central location of the
small bowel; (2) Evidence of small bowel obstruction;
(3) Clustering of the small bowel; (4) Displacement of
and mass effect on adjacent organs; and (5) Stretched,
displaced, crowded, and engorged mesenteric vessels.
No membrane-like sac can be detected in patients with
internal hernias as seen in abdominal cocoon
[11]
. In
chronic idiopathic intestinal pseudo-obstruction, CT
scan showed distention of small ad large bowels and no
membrane-like sac.
TREATMENT AND PROGNOSIS
Management of SEP is debated. Most authors agreed
that surgical treatment is required
[64-66]
. In some cases,
the diagnosis is established at a late stage of the dis-
ease at laparotomy when the patient develops partial or
complete small bowel obstruction. Laparotomy reveals
characteristic gross thickening of the peritoneum, which
encloses some or all of the small intestine in a cocoon
of opaque tissue (Figure 2). The root of the mesentery
may also be sclerotic and retracted. Fibrous bands form
between the loops of bowel, and when the mass of
bowel is sectioned, many small loculated abscesses due
to local perforations are found. The entity was catego-
rized into 3 types according to the extent of the encas-
ing membrane: (1) Type
Ⅰ 
- the membrane encapsulated
partial intestine; (2) Type
- the entire intestine was
encapsulated by the membrane; and (3) Type
- the
entire intestine and other organs (e.g., appendix, cecum,
ascending colon, ovary,
etc.
) were encapsulated by the
membrane
[4]
. Various treatment options are adopted,
such as subtotal excision of the membrane, enterolysis,
small bowel intubation, bowel resection, and explor-
atory laparotomy with postoperative medical treatment
in patients with high perforative risk. When feasible,
a stripping of the membrane with intestinal releasing
without intestinal resection is the treatment of choice.
A simple surgical release of the entrapped bowel
via
removal of the brotic membrane is all that is required
to free the bowel if no other cause of obstruction, such
as a stricture, is found. In order to avoid complications
of postoperative intestinal leakage and short-intestine
syndrome, resection of the bowel is indicated only if it
is nonviable because resection of the bowel is unneces-
sary and it increases morbidity and mortality. In some
patients, repeated adhesiolysis was required. For some
authors, laparoscopic approach was possible to diag-
nosis and management of abdominal cocoon
[67-70]
. An
excellent long-term postoperative prognosis is most of
the times guaranteed with a little risk of recurrence in
long term follow-up. No surgical treatment is required
in asymptomatic SEP. Surgical complications were re-
ported including intra-abdominal infections, enterocuta-
neous stula and perforated bowel
[66]
.
Treatment for secondary SEP in dialysis patients is
cessation of PD, nutritional support, and surgery for in-
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A
B
Figure 1 Computed tomography scan. A: Axial contrast enhanced computed
tomography (CT) scan of the abdomen showing bowel loop mass encased in
a membrane; B: Anterio-posterior CT scan of the abdomen showing thin mem-
brane around bowel loops.
Tannoury J
et al
. Abdominal cocoon
Page 3
testinal obstruction, if required. Treatment was variable,
but in recent years, steroids and tamoxifen were gener-
ally used when SEP was recognized. Preliminary results
suggest that steroids and tamoxifen
[37]
or Angiotensin
inhibitors
[71]
are benecial. Transfer to haemodialysis is
necessary. Prognosis of SEP is poor, with death usually
occurring within a few weeks or months after surgery as
it carries a high mortality (20%-80%). This is the result
of diagnosis in the latter stages of disease when patients
have already developed bowel obstruction. Earlier diag-
nosis, biocompatible dialysates, and immunosuppressive
therapy may improve the outcome for such patients in
the future
[30-37]
.
HISTOPATHOLOGY OF SEP
Histopathology is now seldom required as CT imaging
appearances along with the clinical features allow a con-
fident diagnosis of SEP. Histologically, the peritoneum
shows a proliferation of bro-connective tissue, inam-
matory infiltrates, and dilated lymphatics, with no evi-
dence of foreign body granulomas, giant cells, or birefrin-
gent material
[72-74]
. ‘‘Sclerosing’’ refers to the progressive
formation of sheets of dense collagenous tissue; ‘‘en-
capsulating’’ describes the sheath of new brous tissue
that covers and constricts the small bowel and restricts its
motility; and ‘‘peritonitis’’ implies an ongoing inamma-
tory process and the presence of a mononuclear inam-
matory inltrate within the new brosing tissue
[73]
.
CONCLUSION
Abdominal cocoon, or idiopathic sclerosing encapsulat-
ing peritonitis, is a rare condition of unknown cause
characterized by total or partial encasement of the small
bowel by a brocollagenous cocoon-like sac. Although it
was rst described in tropical and subtropical adolescent
girls, it can occur in all age groups, both genders, and in
several regions of the world. The preoperative diagno-
sis of abdominal cocoon is difficult and the diagnosis
should always be considered whenever a patient reports
episodes of abdominal pain, nausea and vomiting as-
sociated with weight loss. Combination of diagnostic
modalities like sonography and CT scan can help in
making preoperative diagnosis of this entity and prevent
unnecessary bowel resection. This condition should be
managed in specialized centers. Surgery is important in
the management of this disease. Careful dissection and
excision of the thick sac with the release of the small
intestine leads to complete recovery.
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