An intraoperative diagnosis of sclerosing encapsulating peri
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Primary sclerosing encapsulating peritonitis (SEP) is an idiopathic and rare condition characterized by chronic peritoneal inflammation. We describe the case of an intraoperative diagnosis of SEP, presenting as a mimicker of small bowel obstruction, The 59-year-old male presented to hospital complaining of severe nausea and generalized abdominal pain requiring admission. The patient had an episode of gastroenteritis 6 months prior, and since then experienced multiple episodes of colicky abdominal pain with intermittent vomiting. A computed tomography scan was suggestive of subacute small bowel obstruction with a?high suspicion of an internal hernia through an omental defect.

Intraoperatively, thick fibrous tissue involving the visceral and parietal peritoneum was found enveloping grossly dilated loops of small bowel. There was no evidence of a transition point contributing to this patient’s obstruction. As any manipulation or mobilization of the bowel was thought to be high-risk of causing enterotomy, a decision was made to close the abdomen. He was discharged home 9 days following his operation, after demonstrating significant improvement in gastrointestinal function, with reduced pain and able to tolerate oral intake.

There was an associated mild focal chronic inflammatory cell infiltrate including lymphocytes and histiocytes. The mesothelial lining was completely denuded. D2-40 immunohistochemistry showed lymphatic endothelial cells within collagenous fibrous tissue. On retrospective review of the case at a multidisciplinary team meeting, the original scans were reviewed and demonstrated central congregation of the small bowel loops encased within a ‘cocoon-like’ thick peritoneal membrane, characteristic of SEP. A consensus was reached whereby this patient’s presentation was attributed to SEP, otherwise termed ‘abdominal cocoon syndrome’. This diagnosis is exceedingly difficult to make preoperatively, and previous reports have only identified this condition on exploratory laparotomy. Furthermore, given its rare incidence, as well as non-specific clinical and radiological findings, SEP is easily overlooked. This diagnosis was also later confirmed on intestinal ultrasound which demonstrated a centrally clumped ‘cauliflower-like’ appearance of the small bowel, encased within a thickened capsule, depicting a trilaminar sign.