Sclerosing encapsulating peritonitis after living-donor liver transplantation: A case series, Kyoto experience

Abstract

Sclerosing encapsulating peritonitis (SEP), or abdominal cocoon is a rare cause of intestinal obstruction, and still etiology remains unknown. We report a series of 4 patients with abdominal cocoon, and all the 4 patients had previously undergone living-donor liver transplantation (LDLT). There was no evidence of SEP before and during LDLT. At the time of diagnosis of SEP, 3 out of 4 patients had ascites. First and fourth patients had multiple episodes or attacks of cholangitis, which were managed by percutaneous transhepatic biliary drainage and hepaticojejunostomy, respectively. All 4 patients presented with intestinal obstruction and 3 of them underwent a successful operation. The fourth patient died due to liver failure and complications of the SEP. The first 3 patients are doing well without SEP recurrence. Our experience suggest that the prognosis of SEP is poor in patients with poor graft liver functions after LDLT.

Keywords: Abdominal cocoon; Intestinal obstruction; Liver transplantation; Sclerosing encapsulating peritonitis.

Fig. 1. Abdominal computed tomography (CT) scan reveals remarkable ascites, thickening of the peritoneum and fibrous sheaths surrounding the small intestine, and presence of a mechanical intestinal obstruction.

Fig. 2. On laparotomy, the small intestine appears to be encapsulated with a fibrous peel (A). We removed the fibrous membrane, and a total enteroclysis was performed (B).

Fig. 3. Abdominal CT scan reveals small intestinal loops encased by a fibrous sheath with secondary ileus and fluid collection.

Fig. 4. Small intestine wrapped around in a fibrous membrane, consistent with intra-abdominal cocoon. The fibrous peel was removed and adhesiolysis was performed.

Fig. 5. Abdominal CT reveals ascites, splenomegaly, and portal vein thrombosis with collateral veins (A). The CT scan also shows the presence of a fibrous sheath around the intestine with intestinal dilatation (B).

Fig. 6. Abdominal CT reveals ascites, small bowel dilatation, and wall inflammation consistent with sclerosing peritonitis (A). Repeated abdominal CT shows that contrast material did not pass through the colon, and the ileus continued (B).

Fig. 7. Thick fibrotic peel wrapping loops of small bowel.