Asian Journal of Case Reports in Surgery

Background and Aim: Sclerosing encapsulating peritonitis (SEP), also known as abdominal cocoon, is a rare fibro-inflammatory disorder characterised by partial or complete encasement of the small intestine within a dense fibrocollagenous membrane. It may present as intestinal obstruction and is often difficult to diagnose preoperatively. We report an unusual case of idiopathic SEP in an adult male.

Presentation of Case: A 54-year-old man presented with a 4-month history of recurrent diffuse abdominal pain, bloating, progressive abdominal distension and anorexia. There was no history of vomiting or constipation and no previous abdominal surgery. Examination revealed abdominal distension, right lumbar and right iliac tenderness and palpable distended bowel loops. Computed tomography demonstrated gross dilatation of the jejunum and proximal ileum with an apparent transition point in the distal ileum. Diagnostic laparoscopy was attempted but was converted to a limited laparotomy because of dense adhesions and markedly dilated bowel. Approximately 25 cm of ileal loops were found enclosed within a dense fibrocollagenous cocoon-like membrane. Adhesiolysis and excision of the fibrous membrane were performed without bowel resection. Histopathology demonstrated fibrocollagenous tissue with focal mixed inflammation and vascular congestion, confirming sclerosing encapsulating peritonitis. Intraperitoneal fluid examination was negative for tuberculosis.

Discussion: Idiopathic SEP is uncommon and may mimic other causes of small bowel obstruction. Computed tomography may provide characteristic clues, although the definitive diagnosis may be established only during surgery. Careful adhesiolysis and excision of the constricting membrane with preservation of viable bowel are the principal surgical approaches.

Conclusion: Abdominal cocoon should be considered in patients with recurrent or subacute intestinal obstruction, particularly when no conventional cause is identified. Awareness of the condition and careful bowel-preserving surgery can result in satisfactory recovery.