A rare cause of small bowel obstruction: Abdominal cocoon

Abstract

Introduction: The clinical manifestations of abdominal 'cocoon' are non-specific and hence its diagnosis is rarely made preoperatively and the management is often delayed. Surgery remains the main stay of treatment with satisfactory outcome and comprises excision of the fibrous membrane, meticulous adhesionolysis and release of the entrapped small bowel.

Presentation of case: A 45-year-old male patient presented with 6-month history of progressive subacute small bowel obstruction. After initial radiological investigations, he underwent diagnostic laparoscopy and was misdiagnosed as abdominal tuberculosis. He was started on anti-tuberculous therapy, but exploratory laparotomy was carried out after failure to respond to anti-tuberculous therapy. At laparotomy, the abdominal 'cocoon' which was encapsulating the entire small bowel was excised, and the adhesions were carefully lysed. The patient remained well and without recurrence at 1-year follow-up.

Discussion: Abdominal 'cocoon' is a rare cause of subacute, acute and chronic small bowel obstruction. Its diagnosis is rarely made preoperatively.

Conclusion: Abdominal 'cocoon' should be thought of as a rare cause of small bowel obstruction. It may be mistaken with abdominal tuberculosis. Surgery remains the mainstay of curative treatment.

Fig. 1

Computerized tomography scan showing a conglomerate of multiple intestinal loops surrounded by a thick sac-like membrane.

Fig. 2

Operative views: (A) showing the ‘cocoon’ cover of the small bowel. (B) The ‘cocoon’ was opened to release the contained small bowel loops. (C) The adherent loops of small bowel were freed from the sac. (D) Complete excision of the sac and the release of entire small bowel.