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Image of the Month—Diagnosis
Arch Surg. 2006;141:944.
Answer: Abdominal Cocoon
Abdominal cocoon is an unusual peritoneal condition where the small intestine is covered with a dense fibrotic membrane completely or partially. It is also called idiopathic, sclerosing, or encapsulated peritonitis.
Patients are generally adolescent girls from a tropical or subtropical region. The typical age range is between 12 and 18 years; however, patient ages range from 6 to 65 years in the literature.1 Although some authors have found abdominal cocoon in patients using  -blockers or patients with sarcoidosis, systemic lupus erythematosus, and hepatic cirrhosis with or without shunt procedure and peritoneal dialysis, its etiology is still largely unknown. The most frequent symptom is subacute mechanical intestinal obstruction. However, our patient was a 57-year-old man with no known etiologic factor.
Patients with abdominal cocoon are from tropical and subtropical countries in general, especially China, Malaysia, Singapore, Pakistan, India, Nigeria, Kenya, Saudi Arabia, Israel, and South Africa. Crampy abdominal pain, vomiting after meals, nausea, and long periods (2-4 days) between defecations are the most frequent complaints. Although our patient did not have colic abdominal pain, he had evident mechanical intestinal obstructive findings. Chronic constipation was the main complaint when he was admitted to our department.
Preoperative diagnosis of abdominal cocoon is difficult because secondary diagnostic methods do not help identify the condition, and this delays the appropriate intervention.2 We could not identify abdominal cocoon by direct radiography, abdominal ultrasonography, or abdominal-pelvic computed tomography in our case. We diagnosed the abdominal cocoon by laparotomy.
Abdominal cocoon's etiology is still unknown, although viral infections have appeared after gynecological events and exposure to peritoneal dialysis solution and in collagen tissue diseases like scleroderma. Only the small intestine was covered with the thick fibrotic membrane in all known cases.3 Abdominal cocoon may also cause infertility.
In our case, which was different from most described previously in the English-language literature but similar to Serafimidis et al,4 the entire colon from the cecum to the sigmoid colon and both surfaces of the stomach were covered with the fibrotic membrane. We did not determine any pathologic features while examining the stomach-colon motility. Colonic passage and colon size were normal. The fibrotic membrane was dissected by blunt, sharp dissection from the ileocecal junction to the Treitz ligament. All small intestine curves were freed this way (Figure 2). We did not interfere with the fibrotic membrane over the colon and stomach. After careful homeostasis, the operation was terminated.
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Figure 2. Appearance of the small intestine after the dissection.
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Postoperative histopathologic evaluation revealed fibroadipose tissue and fibrin. Oral nutrition was started on the second postoperative day after normal intestinal motility occurred. The patient was discharged from the hospital at the fourth postoperative day. At 4 months' follow-up, he had no additional problems.
In abdominal cocoon cases, surgery is still a current and effective treatment method. Careful dissection and excision of the thick membrane to release the small intestine leads to complete recovery. Abdominal cocoon should be considered in patients who complain of mechanical intestinal obstruction. Early consideration can make the preoperative diagnosis process easier and can prevent bowel injuries by laparoscopy or unnecessary bowel resection during operation.
AUTHOR INFORMATION
Correspondence: Tamer Akca, MD, General Surgery Department, Mersin University Medical Faculty, Zeytinlibahce C, Mersin 33079, Turkey (takca{at}mersin.edu.tr).
Accepted for Publication: August 1, 2005.
REFERENCES
1. Yoon YW, Chung JP, Park HJ, et al. A case of abdominal cocoon. J Korean Med Sci. 1995;10:220-225.
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2. Rajagopal AS, Rajagopal R. Conundrum of the cocoon: report of a case and review of the literature. Dis Colon Rectum. 2003;46:1141-1143.
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3. Ahmad S. Sclerosing peritonitis and propranolol. Chest. 1981;79:361-362.
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4. Serafimidis C, Katsarolis I, Vernadakis S, et al. Idiopathic sclerosing encapsulating peritonitis (or abdominal cocoon). BMC Surg. 2006;6:3.
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