SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2021 | VOLUME 19 | ISSUE 2 | 25 CASE REPORT Multi-level small bowel obstruction due to type 3 idiopathic sclerosing encapsulating peritonitis (SEP) in a young male patient. JJP Buitendag 1 , ER Theron 2 , H Van Zyl 2 , N Allopi 1 , R Dickson-Lowe 3 Department of Surgery, Tygerberg Hospital, University of Stellenbosch, Western Cape, South Africa 1 Department of Surgery, Karl Bremer Hospital, University of Stellenbosch, Western Cape, South Africa 2 Department of General & Colorectal Surgery, Medway Maritime NHS Foundation Trust, Gillingham, UK 3 Patient consent obtained. Introduction: Idiopathic sclerosing encapsulating peritonitis (SEP), also called abdominal cocoon, was initially described by Foo et al for the first in 1978 as a rare condition that can cause bowel obstruction. 1-3 The condition occurs mainly in women and and has a several clinical mimics secondary to specific pathologies.. It is typically characterised by a thick fibrocollagenous membrane encasing the small bowel, but has been documented to involve other organs. 1-3 We present an unusual case of a middle-aged male patient presenting with sub-acute small bowel obstruction secondary to SEP and discuss the condition and the theories of its aetiopathogenesis Case Presentation A 45-year old male presented for the first with a six- month history of intermittent lower abdominal colicky pain worsening constipation. This was associated with post- prandial bilious vomiting and a loss of weight and appetite. He had no prior surgery, comorbidities or allergies and was on no regular medications. There was no history of retroviral disease or tuberculosis. He was a non-smoker who didn’t use recreational drugs or alcohol with a good performance status. The patient was afebrile with a respiratory rate of 16 breaths per minute, a pulse of 102 beats per minute and a blood pressure of 119/77mmHg. His oxygen saturations was 99% on room air. There were no extra-abdominal findings on examination. His abdomen was distended with mild generalised tenderness. There was no organomegaly, but a mass was felt centrally around the umbilicus. Bowel sounds were decreased. Urine dipstick was normal. Serum investigation showed no abnormalities.. An erect Chest radiograph showed no free air under the diaphragm. Supine abdominal radiographs Correspondence Nabeel Allopi email: nabeelallopi@gmail.com Figure 1. Barium follow through with irregularty at the duodeno-jejunal junction with partial obstruction with some duodenal dilatation D3 obstruction as seen on Barium follow through. D4 and proximal jejenum obstruction. showed non-specific dilated loops of bowel. An abdominal CT scan with intravenous and oral contrast showed a distended stomach filled with fluid, with a possible transition point between the second and third part of the duodenum with the remainder of small bowel collapsed. There was peritoneal thickening, with a loop of small bowel that appeared to be aperistalic, non-distensible and in a fixed position. There was no lymphadenopathy or calcification of the lymph nodes Gastroscopy showed a mild pre-pyloric gastritis. A barium follow through showed an irregularty at the duodeno-jejunal junction with partial obstruction with some duodenal dilatation proximal to the obstruction (Figure 1). Initially the patient was