Abdomen cocoon causing chronic abdominal pain and intestinal obstruction; a case series

Abdominal cocoon syndrome (ACS): a case report of a Chinese male diagnosed idiopathic ACS with inborn short intestine

Introduction and importance

Abdominal cocoon syndrome (ACS), as a rare cause of mechanical intestinal obstruction, can be divided into primary/idiopathic vs. secondary type. The primary ACS is often asymptomatic and only diagnosed in exploratory laparotomy. The major treatment of surgery can be challenging. Since the gut wall and peritoneum are densely adhered, gut perforation might occur during adhesiolysis. Thus, it is important to have an experienced surgeon to perform the surgery.

Case presentation

The authors present a primary ACS case of a 50-year-old man. The patient demonstrated an unbearable upper abdominal pain upon admission. A computed tomography (CT) scan showed a severe bowel obstruction. An exploratory laparotomy was indicated, leading to the diagnosis of ACS, which was considered idiopathic after ruling out secondary factors. An adhesiolysis was performed successfully. Note that the entire intestine measured was only 2.1 m during the surgery. There was no post-surgical complication. The patient was recovered uneventfully.

Clinical discussion

The aetiology of primary ACS is unknown. The incidence is comparatively low and considered equal between men and women. As a rare cause of gut obstruction, the suspicion of the diagnosis should be strengthened. Surgery including adhesiolysis and bowel resection remains the major treatment. If adhesiolysis fails, bowel resection will be inevitable. The knowledge and experience of surgeon will be tested.

Conclusion

The aetiology of primary ACS should be further explored. And the differential diagnosis of bowel obstruction should cover ACS in order for the surgeon to be prepared before surgery.

A case report of encapsulating peritoneal sclerosis followed by cesarean section: Clinical diagnosis and treatment experience

RATIONALE

Encapsulating peritoneal sclerosis (EPS), also known as abdominal cocoon syndrome, is an uncommon condition that typically presents with features of bowel obstruction. EPS followed by cesarean section is extremely rare. Intestinal obstruction caused by EPS lacks specificity and poses clinical difficulties for diagnosis and treatment. We present the case of a patient with recurrent intestinal obstruction followed by cesarean section, and the diagnosis of EPS was confirmed intraoperatively. The patient recovered well postoperatively, and achieved satisfactory therapeutic results. Management of this condition tests the surgeon's knowledge and experience of the disease.

PATIENT CONCERNS

A 27-year-old woman with recurrent abdominal pain and distention accompanied by reduced anal discharge and defecation there months. The patient had a history of cesarean section 4 months earlier and recovered well after operation. She had no other history of abdominal surgery or diseases. On examination, a 10-cm long transverse incision was made in the lower abdomen, and marking on the intestinal movements were observed in the left mid-abdomen. A long, soft lump with good mobility was touched in the left lower abdomen. The abdominal computed tomography and small bowel barium meal examination revealed incomplete intestinal obstruction.

DIAGNOSIS

Incomplete small bowel obstruction due to abdominal adhesions after the cesarean section was initially considered.

INTERVENTIONS

After conservative treatment, the symptom of intestinal obstruction still recurred. Thus, we decided to perform a surgery of repeated decortication of fibrous peritoneal membranes.

OUTCOMES

The operation successfully released the intestinal obstruction and abdominal pain, postoperative course recovered smoothly.

LESSONS

After cesarean section could develop EPS. Intestinal obstruction caused by EPS lacks specificity and poses clinical difficulty in diagnosis and treatment. The management of this condition tests the surgeon's knowledge and experience, and surgery is an effective treatment measure.

Abdominal cocoon syndrome (idiopathic sclerosing encapsulating peritonitis): An extremely rare cause of small bowel obstruction-Two case reports and a review of literature

Introduction

Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction in which the bowel and internal abdominal organs are wrapped with a fibrocollagenous cocoon-like encapsulating membrane [1,2]. SEP is divided into two entities: abdominal cocoons (AC), also known as idiopathic or primary sclerosing encapsulating peritonitis, which is of extremely rare type, and secondary sclerosing encapsulating peritonitis, which is the more common type.

Case presentation

Two male patients from India, a 26 year old and a 36 year old, presented to our hospital complaining about abdominal pain associated with nausea and vomiting without any history of previous surgical interventions; the patients' vitals were stable. Preoperative diagnosis of abdominal cocoon was established by abdominal computed tomography. It showed multiple dilated fluid-filled small bowel loops in the center of the abdominal cavity with thin soft tissue, non-enhancing capsules encasing the small bowel loops with mesenteric congestion involving small and large bowel loops. Both patients underwent complete surgical excision of the sac without intraoperative complications. Patients had a smooth postoperative hospital course and were discharged home in good conditions.

Conclusion

Patients with abdominal cocoons have a non-specific clinical presentation of intestinal obstruction. A high index of clinical suspicion in combination with the appropriate radiological investigation will increase the chance of preoperative detection of the abdominal cocoon. In patients with complete bowel obstruction, complete excision of the peritoneal sac is the standard of care.

Is Abdominal Cocoon a Sequela in Recovered Cases of Severe COVID-19?

Abdominal cocoon is one of the rare causes of intestinal obstruction mostly diagnosed at the operating table. Its etiology is primarily unknown but can be secondary to known causes. The involvement of the gastrointestinal (GI) system was a common feature during the second wave of COVID-19, and at present, there are reports of GI symptoms in patients who have completely recovered from COVID-19. Abdominal cocoon formation has been reported during the active stage of COVID-19 but not as its sequela. We report two cases with a high degree of suspicion of abdominal cocoon formation in middle-aged individuals with no comorbidities, who recovered from a severe form of COVID-19.

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 or Encapsulating Peritoneal Sclerosis: A Rare Cause of Small Bowel Obstruction

Encapsulating peritoneal sclerosis (EPS), also known as abdominal cocoon syndrome (AC) or sclerosing encapsulating peritonitis (SEP), is an uncommon condition typically presenting with features of bowel obstruction. We present the case of a 41-year-old male patient who presented to the accident and emergency department with a 7-day history of abdominal pain. Contrast CT of the abdomen and pelvis was ordered and was suggestive of small bowel obstruction involving most of the small bowel with no apparent transition point. Laparotomy showed a tough whitish fibrous membrane encasing the entire length of the small bowel. Advances in CT have made diagnosis possible before a decision on surgical intervention is made.