A 39 year old male was admitted to our hospital with complaints of abdominal pain for years and weight loss of 10 kg within the last year. The pain was colicky, started in center of the abdomen, radiated to the periphery, aggravated by eating. He had no nausea or vomiting, constipation or diarrhea. His appetite was good, but he was afraid to eat. He had no fever. There was no history of illnesses like: familial Mediterranean fever, tuberculosis, sarcoidosis, systemic lupus erythematosus, protein S deficiency, malignancy, ascites or peritoneal dialysis. There was no history of previous abdominal wash (e.g. by povidone iodine). Patient was not on regular medication (e.g. beta-adrenergic blocker). There is no history of travel to tropical or subtropical countries.
On examination he was thin built, with distended non tender abdomen. No organomegaly was observed. Bowel sounds were exaggerated. Digital rectal examination was normal. All his laboratory blood tests were normal. Abdomen CT scan showed clumping of ileal loops at the level of umbilicus, with a thin capsule surrounding it. Small amount of fluid is seen around these bowel loops. The proximal loops appear mildly dilated and distal ileal loops collapsed. No evidence of vascular axis rotation (Figs. 1 and 2).
Upper and lower gastrointestinal endoscopy were unremarkable. Diagnostic laparoscopy showed that most of the small bowel was wrapped up in a grayish-pink membrane forming a cocoon (Fig. 3). The procedure was changed to laparotomy to avoid injury as it was very difficult to release the encased bowel laparoscopically. It seems from the diagnostic laparoscopy and laparotomy view that the membrane is originated from the mesothelial covering of the root of the mesentery. Excision of the whole membrane was done carefully and was sent for pathology examination. Encased small bowel loops were separated by sharp dissection (Fig. 4).
All loops of small bowel were viable. Small bowel full thickness biopsy was taken. Two cm in diameter firm central mesenteric lymph node was excised. Appendectomy was done as the appendix was embedded in the membrane (Fig. 5). All Other abdominal organs were normal. Histopathology of the membrane, showed dense poorly cellular collagenised fibrous tissue, features consistent with sclerosing encapsulating peritonitis (abdominal cocoon; Fig. 6).
Small bowel, appendix and lymph node biopsy were unremarkable. Post operatively the patient showed improvement in his symptoms; with uneventful five months follow up.