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Paper text:
abdominal cocoon is a rare condition , which refers to partial or total encapsulation of abdominal viscera within a dense fibrous membrane .
it has been referred to as  peritonitis chronica fibrosa incapsulata  by owtschinnikow . and
abdominal cocoon is predominantly reported among females from the tropical and subtropical regions ; however , cases of adult males were also reported .
the correct diagnosis is not often made preoperatively , as ct and mri finding are nonspecific .
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 .
there was no history of illnesses like : familial mediterranean fever , tuberculosis , sarcoidosis , systemic lupus erythematosus , protein s deficiency , malignancy , ascites or peritoneal dialysis .
abdomen ct scan showed clumping of ileal loops at the level of umbilicus , with a thin capsule surrounding it .
the proximal loops appear mildly dilated and distal ileal loops collapsed . no evidence of vascular axis rotation ( figs .
diagnostic laparoscopy showed that most of the small bowel was wrapped up in a grayish - pink membrane forming a cocoon ( fig .
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 .
histopathology of the membrane , showed dense poorly cellular collagenised fibrous tissue , features consistent with sclerosing encapsulating peritonitis ( abdominal cocoon ; fig .
post operatively the patient showed improvement in his symptoms ; with uneventful five months follow up .
sclerosing encapsulating peritonitis ( cocoon abdomen ) is a rare condition . with few cases described in literatures .
cocoon abdomen is mostly observed in young girls living in tropical and subtropical countries of the world , especially china , malaysia , singapore , pakistan , india , nigeria , kenya , saudi arabia , israel , and south africa . although few cases have been documented in males .
these include retrograde menstruation with a superimposed viral infection , retrograde peritonitis and cell - mediated immunological tissue damage incited by gynecological infection .
however , since this condition has also been seen to affect males , premenopausal females and children , there seems to be little support for these theories .
the secondary causes of abdominal cocoon include continuous ambulatory peritoneal dialysis , tuberculosis , systemic lupus erythematosus , sarcoidosis , familial mediterranean fever , gastrointestinal malignancy , protein s deficiency , liver transplantation , fibrogenic foreign material , luteinized ovarian thecomas , the use of povidone iodine for abdominal washout , placement of leveen shunt for refractory ascites , as well as the beta - adrenergic blocker ( practolol ) . in our patient , the etiology appears to be primary , as all the known causes of secondary cocoon abdomen were ruled out .
patients with cocoon abdomen may present in one or multiple episodes with symptoms of acute or sub acute small bowel obstruction ( that could sometimes resolve spontaneously ) . in this case , the patient has recurrent attacks of colicky abdominal pain and distension , which was sometimes resolved spontaneously .
abdominal mass may also be present due to an encapsulated cluster of dilated small bowel loops .
a pre - operative diagnosis is usually very difficult and requires a high index of clinical suspicion .
most cases are diagnosed intraoperatively during laparotomy performed for intestinal obstruction , or during diagnostic laparoscopy .
abdominal ultrasonography may be of help in the diagnosis of cocoon abdomen by revealing an echogenic mass of dilated small - bowel loops surrounded by a thick rim of hypoechoic fibrous membrane .
barium follow - through may show delayed transit of contrast and clustering of the bowel loops in the pelvis .
ct findings may include clumping of small bowel loops in the center of the abdomen encased by a soft - tissue density mantle , peritoneal thickening and calcification , clumping of small bowel loops , and lobulated fluid collections . in this study preoperative diagnosis was possible by abdominal ct scan which showed clumping of ileal loops , surrounded by a thin capsule and small amount of fluid .
cocoon abdomen may be confused with congenital peritoneal encapsulation , which is characterized by a thin accessory peritoneal sac surrounding the small bowel , and is an incidental finding .
dissection ( open or laparoscopic ) of fibrotic membrane and adhesiolysis is usually sufficient to treat abdominal cocoon .
complications after surgery were reported ; these include intra - abdominal infections , enterocutaneous fistula and perforated bowel . in this case
follow - up has shown recurrence only in few cases , some of which resolved on conservative management .
primary sclerosing encapsulating peritonitis ( cocoon abdomen ) is rare condition ; with unclear etiology .
it affects young patients and its diagnosis needs a high index of suspicion , as signs and symptoms are nonspecific and imaging findings are not always conclusive .
careful excision of the accessory peritoneal sac and lysis of adhesions between bowels is the best treatment .
the authors have no financial or personal relationships with other people or organisations to disclose .
this study had been approval by the ethics committee in bahrain specialist hospital , manama , kingdom of bahrain .
analysis and interpretation : amer hashim al ani , najah al zayani , mohammad najmeddine , sunitha jacob and sunil nair . manuscript drafted by : amer hashim al ani .
introductionabdominal cocoon ( sclerosing encapsulating peritonitis ) ( sep ) is a rare condition , mostly affecting adolescent girls living in tropical / subtropical region . 
 its etiology is unknown . 
 it may cause acute or sub - acute intestinal obstruction.presentation of casewe report here a 39 year old male who complained of long standing colicky abdominal pain , with significant weight loss . 
 abdomen ct scan showed clumping of ileal loops at the level of umbilicus , with a thin capsule surrounding it . 
 laparoscopy revealed abdominal cocoon , biopsy of which showed dense hypocellular fibro - collagenous tissue with no neoplastic or granulomatous process . 
 excision of fibrous tissue and release of adhesions was done . 
 patient was symptoms free after five months follow up.discussionabdominal exploration is usually needed for the diagnosis and treatment of abdominal cocoon . a thick fibrotic peritoneal wrapping of the bowel is usually found . 
 complete recovery is the result in majority of cases after surgical removal of the wrap causing the cocoon.conclusionprimary sclerosing encapsulating peritonitis ( cocoon abdomen ) diagnosis needs a high index of suspicion , as signs and symptoms are nonspecific and imaging findings are not always conclusive . 
 careful excision of the accessory peritoneal sac and lysis of adhesions between bowels is the best treatment . 
 prognosis is generally good .