Chronic bowel obstruction in a middle-aged man: JAMA case re
A man in his 50s with a history of prostate cancer treated with robotic prostatectomy 2 years ago presented with 1 year of progressively worsening postprandial nausea or vomiting, epigastric abdominal pain, anorexia, and weight loss of 27 kg. Four months earlier, he had presented to another hospital and received a diagnosis of adhesive small bowel obstruction, for which he underwent laparotomy and lysis of small adhesive bands that provided only temporary symptomatic improvement.

At his current presentation, he was unable to tolerate any oral intake and entirely dependent on total parenteral nutrition. On examination, he was cachectic with a moderately distended, nontender abdomen. The result of a blood test was positive for tuberculosis exposure.

An abdominal computed tomography scan showed markedly dilated stomach and duodenum with decompressed, thickened distal small bowel without a clear transition point. Nonoperative management with persistently high nasogastric tube output failed, and the patient was subsequently taken to the operating room for exploratory laparotomy. Intraoperative findings are shown in figure 1.

During surgery, this patient was found to have a thick fibrous sac encapsulating the small bowel along its entire length, from the ligament of Treitz to the ileocecal junction, consistent with sclerosing encapsulating peritonitis (SEP). The opening of the sac revealed the small bowel to be compressed and kinked longitudinally and transversely, resulting in the mechanical obstruction (Figure 2).

Clinical Pearls:-
• Also known as abdominal cocoon syndrome, SEP is a rare cause of intestinal obstruction in which part or all of the small bowel, and sometimes the colon, becomes encased and compressed in a fibrous sac.

• The condition can be primary (idiopathic), classically seen in adolescent girls in tropical latitudes or secondary, most commonly caused by chronic peritoneal dialysis.

• Other known secondary causes include chronic inflammatory or infectious insults such as recurrent peritonitis, intraperitoneal chemotherapy, peritovenous or ventriculoperitoneal shunting, systemic lupus erythematosus, sarcoidosis, abdominal tuberculosis, and parasitic infections.

• Clinical presentation usually includes symptoms of progressive chronic or intermittent intestinal obstruction, such as nausea, vomiting, abdominal pain, weight loss, and abdominal mass.

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