Transcript SCLEROSING ENCAPSULATING PERITONITIS – ROLE OF …

SCLEROSING ENCAPSULATING
PERITONITIS – ROLE OF
IMAGING
ABSTRACT ID: IRIA 1156
LEARNING OBJECTIVES
 There are various causes of intestinal obstruction.
 Imaging plays a key role in establishing preoperative
diagnosis.
 Sclerosing encapsulating peritonitis is a rare benign
cause of acute or sub-acute intestinal obstruction
and has to be considered while evaluating causes for
bowel obstruction.
Background
 Sclerosing encapsulating peritonitis is also called as
Abdominal cocoon. In this the small bowel loops are
partly or completely encased in a thick, fibrous
membrane and hence the name.
 It is common in young adolescent girls from tropical
or subtropical countries.
 It can be idiopathic or mainly secondary to chronic
ambulatory peritoneal dialysis, peritoneo- venous or
ventriculo peritoneal shunts, or treatment with
practolol.
 Rarely it can occur in people with chronic abdominal
disorders like tuberculosis, sarcoidosis, malignancies
etc.,
 Abdominal distention, pain and vomiting are the
common presenting features that may resolve
spontaneously. The patient may have multiple such
episodes.
CASE HISTORY
 A 36 yr old male presented with abdominal
distention and pain for four days. he had similar
episodes in the past 2 yrs.
 He had no history of previous surgical interventions
or chronic infectious disorders.
 There was no family history of tuberculosis.
 Complete blood count , electrolytes and other
routine laboratory investigations were within normal
range.
IMAGING
 Abdominal Ultrasonography was done and dilated,
aggregated small bowel loops with altered peristalsis
were seen in abdomen. Mild inter-loop fluid was
seen along with few enlarged mesenteric nodes.
 A supine radiograph of abdomen was taken which
showed dilated bowel loops.
 A provisional diagnosis of sub acute intestinal
obstruction was made.
 In view of aggregation of bowel loops with
mesenteric nodes , subsequently Computed
tomography[CT ] was done.
CT Abdomen
 Contrast enhanced CT abdomen showed dilated,
aggregated bowel loops in the centre of abdomen
surrounded by enhancing membrane forming sac
and giving the appearance of a cocoon.
 Mild inter loop fluid and multiple mesenteric nodes
were seen.
 In addition to this a small loculated pleural effusion
was seen in the right posterior costo-phrenic angle.
With this along with mesenteric nodes, tuberculous
etiology was suspected.
 Differential diagnosis include Internal hernias and
congenital peritoneal encapsulation.
 Internal hernias show stretched, displaced, crowded,
and engorged mesenteric vessels and no membrane
like sac can be detected.
 Congenital peritoneal encapsulation, is
characterized by a thin accessory peritoneal sac
surrounding the small bowel found incidentally and
is asymptomatic.
Sequential axial sections of CECT abdomen showing small bowel loops
extending from left upper quadrant to the centre of abdomen inferiorly
and are covered by enhancing membrane.
Axial and coronal reformatted images showing sac like
membrane encasing the bowel loops.
Sagittal reformatted images showing clustered
small bowel loops in a membrane.
Loculated effusion in right thorax
 A diagnosis of abdominal cocoon secondary to
Tuberculosis was made.
 Exploratory laporatomy was done and a thin fibrous
sac seen encasing the bowel loops. The membrane
was resected and sent for histo-pathological
examination along with the drained fluid.
 Histo pathological examination showed epitheloid
granulomas in the membrane.
 a
 b
a. Intra operative image showing the encapsulating
membrane. b.HPE slide showing epitheloid
granuloma.
CONCLUSION
 Abdominal cocoon is a rare but surgically treatable
cause of intestinal obstruction.
 Imaging plays a key role in timely preoperative
diagnosis and thus can help in preventing extensive
resection of bowel.
 Though rare abdominal cocoon should be included
in the differential diagnosis, while investigating for
intestinal obstruction.
 In our country where tuberculosis is more prevalent,
with appropriate clinical settings, Imaging helps to
clinch the diagnosis.
REFERENCES
 Meryem Cereb Tombak, F. Demir Apaydın, Tahsin Colak
etal. An Unusual Cause of Intestinal Obstruction:
Abdominal Cocoon, AJR 2010; 194:W176–W178.
 Rajul rastogi. Saudi J Gastroenterol.Jul 2008.
 MustafaKemalDemir, MD. OkanAkinci, MD.
EnderOnur, MD. NesetKoksal,MD. Sclerosing
Encapsulating Peritonitis. Radiology: Volume 242:
Number 3—March 2007 .
 . Wig JD, Gupta SK. Computed tomography in
abdominal cocoon. J Clin Gastroenterol 1998;26:156–
157.
THANK YOU