Sclerosing encapsulating peritonitis (abdominal cocoon) after abdominal hysterectomy

Abstract

Sclerosing encapsulating peritonitis (SEP) is a poorly understood and rarely documented cause of small bowel obstruction. Although recurrent peritonitis has been reported as the main contributory factor leading to secondary SEP, the pathogenesis of primary (idiopathic) SEP is still uncertain. A 40-year-old woman with a history of total abdominal hysterectomy due to gestational trophoblastic disease presented with progressive lower abdominal pain and abdominal distension. Ultrasonography and contrast-enhanced abdomen-pelvis computed tomography of the abdomen revealed encapsulation of the entire small bowel with a sclerotic capsule. At laparotomy, a fibrous thick capsule encasing small bowel loops was revealed. Extensive adhesiolysis and removal of the capsule from the bowel loops were performed. The patient recovered uneventfully; she was discharged without complications. SEP is a rare cause of small bowel obstruction. We treated a case of abdominal cocoon with intestinal partial obstruction in a woman with a history of abdominal hysterectomy due to gestational trophoblastic disease. Surgical treatment was effective and the patient recovered without complication.

Figure 1

Plain abdominal X-ray shows marked small bowel dilatation and air collection in the lumen with multiple air fluid levels in the upright position. The distended bowel loop was located centrally and extensively folded (A: supine position, B: upright position).

Figure 2

Ultrasound of the abdomen shows small bowel surrounded by a continuous membranous structure. The thickness of the capsule was from 3.5 mm up to 6.1 mm.

Figure 3

(A) Contrast-enhanced abdomen-pelvis computed tomogram shows encapsulation of the entire small bowel with a sclerotic capsule. (B) Abdomen computed tomogram after intake of gastrograffin shows encapsulation of the small bowel from the distal jejunum to the mid ileum.

Figure 4

Barium follow-through shows the entire dilated small bowel loop aggregated and deviated to left side of abdomen. There was no ulcerative change or obstructive material in the lumen of the bowel and normal peristalsis. A trace of barium in the ascending colon suggested little continuity from the small bowel to the colon.

Figure 5

Laparotomy exploration revealed encapsulation of the entire small bowel with a whitish leather like fibrous membrane. Adhesiolysis of the capsule encasing the bowel was performed.

Figure 6

The microscopic findings of the capsule shows dense collagenous fibrous tissue with mild chronic inflammation (A: ×100, B: ×200, H & E stain).