Idiopathic Sclerosing Encapsulating Peritonitis in a Patient with Atypical Symptoms and Imaging Findings

Sclerosing Encapsulating Peritonitis: Solving the Diagnosis Challenge of a Rare Entity

Sclerosing encapsulating peritonitis (SEP) is an unusual fibroinflammatory disease of the peritoneum marked by the development of a fibrous membrane enveloping generally the small intestines. The knowledge around this subject is not completely understood. And the etiology can be either idiopathic or secondary to several diseases, treatments, and/or medications. We present a case of a 52-year-old man suffering from atypical clinical symptoms including recurrent abdominal ascites and intestinal obstruction. An abdominal computed tomography showed findings typical of SEP. Therefore, the patient benefited from exploratory laparotomy, which confirmed the diagnosis of idiopathic SEP. Postoperatively, he again had an episode of bowel obstruction, but this was controlled with steroids. Diagnosis of SEP is a real challenge to surgeons, gastroenterologists, and radiologists. And imagery is very helpful to make the diagnosis. Consequently, it is imperative that all hospital practitioners should distinguish between this lesion and other etiology of acute peritonitis.

Primary sclerosing encapsulating peritonitis: a case report

BACKGROUND

Sclerosing encapsulating peritonitis is a rare condition with a typical macroscopic appearance, with fibrocollagenous membrane enclosing loops of the small intestine, causing intestinal obstruction. Unexplained recurrent abdominal pain, obstruction, and a large array of other possible clinical signs and symptoms make sclerosing encapsulating peritonitis a diagnostic challenge.

CASE PRESENTATION

A 48-year-old man of Persian ethnicity was admitted multiple times to the emergency surgery department due to recurrent sudden abdominal pain and chronic obstruction without significant findings in medical history or clinical evaluation. Computed tomography was positive for proximal jejunal dilatation and duodenojejunal flexure stenosis due to internal mesenteric hernia. Exploratory laparoscopy, followed by laparotomy, confirmed thick membrane-like fibrous tissue with complete small intestinal loop envelopment. Extensive membrane excision and adhesiolysis was performed, but no mesenteric herniation was found. Early postoperative paralytic ileus with introduction of low-dose steroid therapy, based on histopathological and immunological results, confirming type III sclerosing encapsulating peritonitis, was completely resolved.

CONCLUSION

Sclerosing encapsulating peritonitis is a rare and difficult-to-diagnose condition, further divided into primary and secondary sclerosing encapsulating peritonitis, on the basis of underlying etiology, dictating treatment modality and prognosis. Intraoperative diagnosis and surgical treatment are mandatory, besides a wide variety of abdominal computed tomography scans, inconclusive results, and clinical presentations. There are so far no known specific markers for the diagnosis of sclerosing encapsulating peritonitis.

Surgical timing for primary encapsulating peritoneal sclerosis: A case report and review of literature

BACKGROUND

Primary encapsulating peritoneal sclerosis (EPS) is a rare but devastating disease that causes fibrocollagenous cocoon-like encapsulation of the bowel, resulting in bowel obstruction. The pathogenesis, prevention, and treatment strategies of EPS remain unclear so far. Since most patients are diagnosed during exploratory laparotomy, for the non-surgically diagnosed patients with primary EPS, the surgical timing is also uncertain.

CASE SUMMARY

A 44-year-old female patient was referred to our center on September 6, 2021, with complaints of abdominal distention and bilious vomiting for 2 d. Physical examination revealed that the vital signs were stable, and the abdomen was slightly distended. Computerized tomography scan showed a conglomerate of multiple intestinal loops encapsulated in a thick sac-like membrane, which was surrounded by abdominal ascites. The patient was diagnosed with idiopathic EPS. Recovery was observed after abdominal paracentesis, and the patient was discharged on September 13 after the resumption of a normal diet. This case raised a question: When should an exploratory laparotomy be performed on patients who are non-surgically diagnosed with EPS. As a result, we conducted a review of the literature on the clinical manifestations, intraoperative findings, surgical methods, and therapeutic effects of EPS.

CONCLUSION

Recurrent intestinal obstructions and abdominal mass combined with the imaging of encapsulated bowel are helpful in diagnosing idiopathic EPS. Small intestinal resection should be avoided.