Coexistence of abdominal cocoon, intestinal perforation and incarcerated Meckel's diverticulum in an inguinal hernia: A troublesome condition

Abstract

Sclerosing encapsulating peritonitis (SEP) is a rare disease entity, in which the small intestine becomes encased and mechanically obstructed by a dense, fibrotic membrane. The disorder is characterized as either primary (idiopathic) or secondary to other causes. The idiopathic cases of SEP, which lack any identifiable etiology according to clinical, radiological and histopathological findings, are also reported under the designation of abdominal cocoon syndrome. The most frequent presenting symptoms of all SEP cases are nausea, vomiting, abdominal distention and inability to defecate, all of which are associated with the underlying intestinal obstruction. Persistent untreated SEP may advance to intestinal perforation, representing a life-threatening condition. However, preoperative diagnosis remains a particular clinical challenge, and most diagnoses are confirmed only when the typical fibrous membrane encasing the small intestine is discovered by laparotomy. Here, we report the clinical presentation of an 87-year-old male with signs of intestinal obstruction and the ultimate diagnosis of concurrent abdominal cocoon, right incarcerated Meckel's diverticulum, and gastrointestinal perforation in laparotomy.

Keywords: Cocoon syndrome; Meckel’s diverticulum; Perforation; Sclerosing encapsulating peritonitis.

Figure 1

X-ray plain abdominal imaging (posteroanterior) revealed intestinal obstruction with marked small bowel air-fluid levels.

Figure 2

Intraoperative photographs taken along the midline incision and showing the encapsulated small bowel segments with a dense fibrous layer.

Figure 3

Intraoperative photographs showing the Meckel’s diverticulum incarcerated within the right inguinal canal (arrow).