SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2021 | VOLUME 19 | ISSUE 2 | 27 CASE REPORT according to extend of involvement, in type 1 only part of the intestine is involved, type 2 the entire intestine involved. In type 3 the appendix, caecum, ascending colon, liver, stomach or ovaries are involved together with entire intestine. A number of hypotheses have been proposed regarding the aetiopathogenesis of this condition. Retrograde menstruation, peritonitis and cell mediated immunological tissue damage due to a gynaecological infection has been proposed but this does not explain the mechanism in males who are also affected by this condition. 1 Another hypotheses purports that embryonic abnormalities such as greater omentum hypoplasia are the cause . 1 SEP can present with nausea, vomiting, recurrent abdominal pain and with features of bowel obstruction. Due to the encapsulating nature of this condition a non tender abdominal mass can often be palpated. 2,3 Plain radiographic films can show nonspecific dilated loops of bowel with air-fluid levels. CT with contrast studies can show enclosed small bowel in thickened peritoneum with proximal small bowel dilatation and an increased transit time. 8 Computerized Tomography is often used to make the diagnosis, however in the majority of cases the diagnosis is made intra operatively. The features on CT is the recognition of the small bowel loops positioned in the middle of the abdominal cavity and be encased by a thickened membrane. 8 There will also be enhancing of the peritoneum with thickening of more than 2mm. There can Table 1. Other mimics of SEP Infective Abdominal tuberculosis, granulomatous peritonitis due to parasite infection, cytomegalovirus peritonitis, recurrent peritonitis Congenital Adhesions causing internal herniation Inflammatory/Immune- mediated Crohn’s disease, IGG4-related disease, sarcoidosis, systemic lupus erythematosus, familial Mediterranean fever Drug related Asbestos exposure, chemotherapy (e.g. Methotrexate), beta blockers (e.g. practolol timolol/propranolol) Surgical/medical procedures Peritoneal dialysis, perito-venous shunts, ventriculoperitoneal shunts, intraperitoneal chemotherapy, liver transplant, trauma related Systemic Protein S deficiency be signs of small bowel obstruction and fixation of small bowel loops. Ascites, bowel wall thickening, and calcified lymph nodes have been reported. Intra-operatively one can appreciate the thickening of the peritoneum that encases the bowel and seldomly other organs. 9 The gold standard of treatment for symptomatic patients is considered release of the membrane with intraoperative adhesiolysis. 9 Outcomes for these patients is usually good with recurrent bowel obstruction seen in only 5.9%. 6 Unfortunately, some patients require multiple adhesiolysis operations over their lifetime for this idiopathic disease process. Our case had typical and atypical features of this condition. The patient had multiple bouts of constipation and bilious vomiting over a six-month period. He had no comorbidities or surgical history suggestive of other mimics of this condition. No laboratory results performed had any abnormalities. Imaging was suggestive of SEP but the condition was not considered due to its rarity. Intra-operatively the patient had multi-level obstruction with encasing membranes. and thus, the diagnosis was entertained only after operative findings. Interestingly the patient was a young male, not in keeping with some of the proposed theories of aetiopathogenesis. Patient consent obtained to publish this account of his illness. Acknowledgements Dr A E Victor, Head of Surgery Karl Bremer, for the intraoperative photos and advice. Dr J Van Der Westhuizen, Anatomical Pathology Tygerberg Hospital NHLS, for the histology image and report. References 1. Xu P, Chen LH, Li YM. Idiopathic sclerosing encapsulating peritonitis (or abdominal cocoon): a report of 5 cases. World J Gastroenterol. 2007;13:3649–3651. 2. Wei B, Wei HB, Guo WP, Zheng ZH, Huang Y, Hu BG, Huang JL. Diagnosis and treatment of abdominal cocoon: a report of 24 cases. Am J Surg. 2009;198:348–353. 3. Mohanty D, Jain BK, Agrawal J, Gupta A, Agrawal V. Abdominal cocoon: clinical presentation, diagnosis, and management. J Gastrointest Surg. 2009;13:1160–1162. 4. Tannoury JN, Abboud BN. Idiopathic sclerosing encapsulating peritonitis: Abdominal cocoon. World J Gastroenterol 2012; 18:1999–2004. doi: 10.3748/wjg.v18. i17.1999. 5. Stone JH, Zen Y, Deshpande V. IgG4-related disease. N Engl J Med 2012; 366:539. 6. Machado NO. Sclerosing Encapsulating Peritonitis: Review. Sultan Qaboos Univ Med J. 2016;16(2):e142-e151. doi:10.18295/squmj.2016.16.02.003 7. World J Gastroenterol. May 21, 2019; 25(19): 2294-2307 8. Hur J, Kim KW, Park MS, Yu JS. Abdominal cocoon: preoperative diagnostic clues from radiologic imaging with pathologic correlation. AJR Am J Roentgenol. 2004;182:639– 641. 9. Liu HY, Wang YS, Yang WG, Yin SL, Pei H, Sun TW, Wang L. Diagnosis and surgical management of abdominal cocoon: results from 12 cases. Acta Gastroenterol Belg. 2009;72:447–449.