Clinical History
A 27-year-old female patient presented with features of generalized abdominal pain mainly at right iliac fossa. The surgeon suspected appendicitis versus rupture of ovarian cyst at ultrasound (not shown; revealed mild free pelvic collection) and ordered CT pelvis and abdomen with oral and IV contrast.
Imaging Findings
CT pelvis and abdomen revealed conglomerated dilated small bowel loops (Fig. 1, 2) with small bowel fecal sign (Fig. 2) suggesting small bowel obstruction with transition point at right iliac fossa with mild to moderate pelvic collection (Fig. 1). Delayed film (3 hours) was taken to assess passing of oral contrast to colon yet the contrast was still seen within the small bowel (Fig. 3). An ultrasound-guided sampling of pelvic collection was obtained and revealed serosanguineous fluid.
On exploration, small bowel loops were enclosed by a slightly thick cocoon membrane (Fig. 4). The membrane was gently peeled off the bowel. Rereading the CT after these intraoperative findings was done and the membrane was seen.
Discussion
Abdominal cocoon syndrome (sclerosing peritonitis) is characterized by a thick fibrous membrane that encloses the small bowel loops. [1] In preoperative assessment, we should put it as a differential diagnosis for intestinal obstruction. The patient usually presented with recurrent attacks of abdominal colics or episodes of intestinal obstruction. With clinical suspicion the CT scan plays an important role in diagnosis as well. [2] Multiple finding could be seen in CT including sites with congregated small-bowel loops in a single area surrounded by a thick enhancing membrane. [3] Usually the cocoon involves the small bowel yet some studies show that it can extend to involve the liver, spleen and stomach. Treatment is mainly surgical by cutting the membrane and releasing the bowel. [4]
Differential Diagnosis List
Abdominal cocoon was proven intraoperatively
Internal hernia
Other causes of small bowel obstruction.
Final Diagnosis
Abdominal cocoon was proven intraoperatively
