Abdominal cocoon is a rare cause of intestinal obstruction. It is difficult to diagnose in most of the cases preoperatively. Surgical removal of the membrane resulted in complete recovery in the majority of the cases. The exact etiology of abdominal cocoon is still unknown. We reported a male patient who presented with features of intestinal obstruction and has been diagnosed as abdominal cocoon intraoperatively.
Abdominal cocoon is a rare condition that refers to total or partial encapsulation of the small bowel by a fibrocollagenous membrane or cocoon with local inflammatory infiltrate leading to acute or chronic bowel obstruction [
A 41-year-old male patient was admitted to the general surgery department of our hospital, complaining of abdominal pain, nausea, and vomiting. He had clinical history of several attacks of abdominal pain over the last seven months. He is a known case of eczema and was on local steroids since four years. The patient had no history of previous abdominal operation. On physical examination, a soft, nontender, and mobile mass was palpated in the right half of the abdomen. No hepatomegaly or splenomegaly was observed. Bowel sounds were a bit hyperactive, and rectal examination was normal. There was no abnormality in the complete blood count and blood chemistry.
CT abdomen revealed multiple clumped small bowel loops in the lower abdomen on the right side with no passage of oral contrast. The adherent bowel loops showed wall enhancement with contrast (Figure
CT showing membrane enveloping loops of small bowel.
The patient underwent emergency explorative laparotomy. The entire small bowel was found to be encased in a cocoon-like fibrous membrane which extended laterally to involve ascending and descending colon (Figure
Intraoperative photograph shows the encapsulated small bowel with a dense fibrous layer.
Intraoperative findings showed encapsulation of small bowel by a dense whitish membrane as a cocoon, which was excised and adhesiolysis was done to release the loops of the intestine. The histological examination of the membrane revealed fibrous tissue focally lined by flatted mesothelial cells with scattered mononuclear inflammatory cell infiltrate and tissue culture fibroblasts. The patient showed a significant recovery postoperatively and was discharged from the hospital uneventfully.
The preoperative diagnosis of abdominal cocoon is difficult and hence, the diagnosis is usually confirmed by laparotomy. The signs and symptoms of abdominal cocoon are usually nonspecific [
Abdominal cocoon could be classified as primary (idiopathic) or secondary [
Review of the literature for abdominal cocoon.
Authors | Year | Age and gender | Country | Clinical association |
---|---|---|---|---|
Devay et al. [ |
2006 | 30-year male | Turkey | Acute appendicitis |
She et al. [ |
2012 | 47-year woman | Hong Kong | Peritoneal dialysis |
Sarmast et al. [ |
2012 | 30-year male | India | Tuberculosis |
Serter et al. [ |
2012 | Turkey | ||
Chatura and Nayak [ |
2012 | 14-year girl | Indian | Tuberculosis |
Kayastha and Mirza [ |
2012 | 13-year girl | Pakistan | Suspected Acute appendicitis |
Noormohamed and Kadi [ |
2012 | N/A | UK | Peritoneal dialysis |
Hur et al. [ |
2004 | 34-year woman |
South Korea | Unknown |
This paper | 2012 | 41-year male | Qatar | Unknown |
The causative factor for primary form remains unknown, which might be caused by a subclinical peritonitis leading to the formation of a cocoon [
It is challenging to diagnose abdominal cocoon preoperatively, as these patients usually presented with normal biochemical investigations and imaging findings apart from CT and MRI are nonspecific [
CT findings are consistent in diagnosing abdominal cocoon [
Encasement of the whole or part of the small bowel in a thick shiny membrane is a characteristic finding of abdominal cocoon [
In conclusion, abdominal cocoon is a rare cause of small bowel obstruction. The preoperative diagnosis requires a high index of suspicion, supported by clinical data and imaging findings indicative of the condition. However, most cases are diagnosed at exploratory laparotomy.
The authors thank all the general surgery staff for their cooperation. The authors have no conflict of interest and no financial issues to disclose. All the authors read and approved the paper.