SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2021 | VOLUME 19 | ISSUE 2 | 26 CASE REPORT managed conservatively with nasogastric tube decompression and intravenous crystalloid fluids to restore his intravascular volume. As there was no clinical improvement after 48 hours, the decision was made to perform a laparoscopy at which a complete encasement of small bowel was noted and the procedure was converted to a laparotomy. All the small bowel was encaseded within a dense fibrocollagenous membrane. The encasing sacs were opened with sharp dissection , and viable bowel loops were found beneath. (Figure 2 and 3). At the duodenojejunal flexure, a similar encasement, accounting for the images obtained on the barium study, was also released. No bowel resection was performed. The membrane was sent for histology. Histology reported that the adhesions Figure 2. Small bowel was encased within a dense fibrocollagenous membrane Figure 4. Collagenous stroma with associated plump, spindled fibroblasts and myofibroblasts Proximal jejenum exposed after incision of encasing membrane. Figure 3. Small bowel was encased within a dense fibrocollagenous membrane Membrane encasing part of the jejenum at multiple levels. are composed of a collagenous stroma with associated plump, spindled fibroblasts and myofibroblasts. Numerous thin- walled blood vessels are seen in the background. (Figure 4). No features of peritonitis or a neoplastic process were seen. The histopathologist confirmed that the specimen had features of SEP. Microbiology confirmed that the membrane grew no organisms. The patient made an uneventful postoperative recovery but defaulted his scheduled outpatient follow up. Discussion: Patients with SEP usually have multiple presentations to the emergency unit with colicky abdominal pain and symptoms of sub-acute bowel obstruction that resolve with supportive management,leading to difficulty in establishing an accurate diagnosis, as postoperative adhesions are the most common cause of these symptoms. In the absence of prior surgery internal herniation, intestinal malrotation, gastric outlet obstruction or secondary peritonitis are more likley diagnoses than SEP which is extremely rare . 4 SEP is a chronic inflammatory condition with an unknown cause and is believed to be the result of recurrent low grade/ subclinical peritonitis with no specific abdominal signs or symptom. Over time this process progresses to sclerosis and membrane formation leading to “cocoon” formation. 6 This condition has been typically described in young females from tropical and subtropical regions. 1 The incidence of idiopathic encapsulation is unknown as the majority of cases are diagnosed intra-operatively. Encapsulating bowel diseases can be classified by cause; into congenital, which is congenital peritoneal encapsulation, and acquired (fibrotic peritoneal encapsulation). Acquired can then be further subdivided into idiopathic also known as abdominal cocoon and secondary to other known causes. These causes include: peritoneal dialysis, abdominal trauma, peritoneal shunts, medications, SLE, malignancy, sarcoidosis and infections. 7 The incidence of secondary encapsulation form peritoneal dialysis is 1,2% but rises to 15% after 6 years and 38% after 9 years in patient with peritoneal dialysis. 1 IGG4 related disease, an immune-mediated fibroinflammatory condition that can affect multiple organs is another potential cause of cocooned small bowel . 5 See Table 1 for other mimics of this condition. Encapsulating bowel disease can also be classified Higher magnification of the adhesions reveal plump, spindled fibroblasts and myofibroblasts set in a collagenous stroma with a few lymphocytes seen scattered in the background.