Abdominal Cocoon: A Forgotten Diagnosis

Abstract

Aims: Sclerosing Encapsulating Peritonitis (SEP), also known as cocoon syndrome, is a rare pathological condition characterized by the complete or partial encapsulation of the small bowel by a fibro-collagenous membrane. Study Design:  Case report. Presentation of Case: We present a case of a 38-year-old woman with subacute intestinal obstruction, ultimately diagnosed with SEP. The patient exhibited chronic abdominal pain, bloating, nausea, vomiting, and an 8 kg weight loss. Clinical examination revealed ascites, gross abdominal distension, and mildly elevated C-reactive protein. Imaging studies demonstrated massive ascites, omental cake appearance, and a right latero-uterine mass. Laparoscopy initially revealed clear ascites, but subsequent laparotomy unveiled a dense membrane encapsulating the small intestine and parts of the colon. Adhesiolysis and partial membrane excision were performed, leading to a successful outcome with the patient discharged on the seventh postoperative day. Discussion: SEP, a rare condition, can be primary (abdominal cocoon syndrome) or secondary, associated with factors like peritoneal dialysis or abdominal surgeries. Diagnosis, challenging and often intraoperative, relies on CT imaging showcasing peritoneal changes. Conservative treatment, emphasizing bowel rest and nutrition, is recommended for minor symptoms. Severe cases may require surgical intervention, including adhesiolysis and membrane excision. SEP carries mortality rates of 26 to 58 percent, with malnutrition and sepsis as common causes of death. Conclusion: SEP poses diagnostic challenges, often requiring surgical exploration. Preoperative diagnosis through a combination of imaging guides appropriate management, avoiding unnecessary surgeries and optimizing patient outcomes.