Difficult to Diagnose the Cause of Intestinal Obstruction du
Abdominal cocoon syndrome, also known as sclerosing encapsulating peritonitis (SEP), is a condition in which the small intestine is partially or completely encapsulated by a fibrocollagenous membrane. It is difficult to diagnose preoperatively. A 46-year-old male patient was admitted to the gastrointestinal surgery clinic with abdominal pain, nausea, vomiting, and a mass in the abdomen which he had discovered himself. His medical history was otherwise unremarkable. However, two to three times in the past he had experienced abdominal pain, nausea, and vomiting attacks that spontaneously regressed within 1–2 days after onset. The physical examination revealed abdominal distension, auscultatory hypoactive intestinal movements, and a palpable mass in the upper left quadrant of the abdomen. Blood tests showed no abnormalities. Abdominal computed tomography (CT) showed dilatation of the stomach and the first, second, and third parts of the duodenum, and a capsule encircling the intestinal loops. Proximal jejunal loops were dilated with a diffusely thickened wall and post-dilation stenosis. Upper gastrointestinal endoscopy and colonoscopy findings were normal. Abdominal computed angiography was performed and showed all mesenteric vessels were patent with no signs of compression, filling defects, or stenosis. Magnetic resonance (MR) enterography showed delayed gastric emptying, duodenal dilatation and stenosis, and wall thickening of the proximal jejunal segments.

Oral intake was interrupted and total parenteral nutrition introduced. A nasogastric tube was placed for decompression. After electrolyte correction and fluid replacement, an exploratory laparotomy was performed. Intraoperatively, the liver and the spleen were seen to have adhered to the diaphragm. The small bowel was encapsulated with a thick fibrous membrane all the way from the ligament of Treitz to the terminal ileum. Bowel movements were restricted and the length of the small intestine was shorter than usual. The bowel was freed with adhesiolysis and the membranous sac removed. The postoperative period was uneventful and the patient was discharged on postoperative day 6. At a 3-month follow-up, physical examination and abdominal x-ray showed no signs of intestinal obstruction. The pathologist reported mononuclear inflammatory cells, multinuclear giant cells, and degenerated mesothelial cells in the peritoneal fluid. Fibrous tissue fragments, hyalinized lipomatosis tissue and multinuclear inflammatory cells were reported in the tissue specimens.