SCLEROSING ENCAPSULATING PERITONITIS: A RARE CAUSE OF BOWEL OBSTRUCTION

Objectives:

Introduction:

Sclerosing encapsulating peritonitis (SEP), also referred to as abdominal cocoon syndrome is a rare cause of bowel obstruction characterized by a thickened fibrous peritoneum that encapsulates the intestines. The exact etiology is idiopathic but may be associated with long term peritoneal dialysis (PD). In the absence of risks factors for adhesive disease, pre-operative diagnosis can be difficult and may require operative intervention or advanced imaging to diagnose. Thus, inclusion of SEP in the differential diagnosis for bowel obstruction is essential for early detection. Existing literature is focused on renal disease as an origin, but it can be multifactorial. Here, we discuss a case of sclerosing encapsulating peritonitis in a patient without known risk factors. 

Case Report:

The patient is a 67-year-old male with multiple medical co-morbidities but no past surgical history or history of PD who presented with diffuse abdominal pain, nausea, vomiting, and obstipation concerning for a small bowel obstruction. He had presented similarly two months prior and improved with conservative management. Several dilated small bowel loops that appeared to be grouped around mesenteric vessels were noted on CT and the decision was made to take the patient to the operating room for exploration. On diagnostic laparoscopy, the peritoneal lining was found to have a smooth fibrous coating and there were several nodules noted on the liver. At that time, exploratory laparotomy was performed. The entire small bowel from the ligament of Treitz to the terminal ileum was found to be adherent to itself with a fibrous coating resembling peritoneal lining (see Figure 1). These findings were determined to be consistent with SEP. Given the chronic nature of this condition, the decision was made to place a decompressive gastrostomy tube and the operation was terminated.


Discussion:

This case highlights a case of SEP in the absence of known risk factors. It remains critical to the general surgeon that a high index of suspicion be exhibited when managing recurrent small bowel obstructions without surgical history or evidence of hernias. Additionally, conservative management can be attempted in a rural setting while reserving definitive intervention for tertiary care centers. To our knowledge, placement of a decompressive gastrostomy tube has not been described in patients with SEP, but it has allowed the patient to manage obstructive symptoms without requiring hospital admission. It should therefore be considered whenever SEP is encountered, particularly when co-morbid conditions may be prohibitive of more invasive intervention.

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