*
Classified Specialist (Surgery), UN Mission. +Classified Specialist (Anaesthesiology), MH Agra Cantt. #Classified Specialist (Pathology),MH Ambala Cantt. **Senior Advisor (Surg & Orthopaedics), 166 MH, C/o 56 APO. ++Ex-Commandant, MH Kirkee, Pune.
Received : 24.8.2004; Accepted : 25.2.2005
Introduction生日歌词
T
he abdominal cocoon is a rare entity, characterid by a total or partial encament of the small bowel by thick fibrotic membrane. 35 cas have been reported since it was first described by Foo et al [1]. It occurs primarily in females. Preoperative diagnosis is a matter of challenge and usually made at laparotomy. We report a patient with acute intestinal obstruction and abdominal cocoon which was diagnod perioperatively.
Ca report
良性纤维瘤
13 year old daughter of a soldier was admitted on 25 Sep 2003 with pain left lower abdomen and vomiting of 6 hours duration. She had a similar episode of pain twice when she was treated conrvatively.
She had not attained menarche and family history was non-contributory. On examination she was averagely built and nourished. Her vitals were normal and she had no pallor or lymphadenopathy. Abdomen was mildly distended, and tenderness was prent to the left of umbilicus. A sausage shaped lump was felt in left umbilical region, size 8x4cm, with concavity towards midline. Margins of the lump were ill defined, soft in consistency, non-pulsatile, mobile and the lump was intra-abdominal. Bowel sounds were prent and there was no shifting dullness. Hernial sites were normal. Per rectal examination was normal. Routine investigations were normal. Plain radiograph abdomen showed multiple fluid and gas levels in the erect position. Ultrasound abdomen showed gas filled loops of small bowel with incread peristalsis,suggestive of small bowel loop obstruction. A diagnosis of acute intestinal obstruction was made. Exploratory laparotomy was performed under general anaesthesia through midline incision. The whole small bowel was adhered together like a cocoon from the duodeno-jejunal flexure to the ileo-caecal region, encapsulated within a peritoneal membrane with adhesions extending from jejunum to left parietal peritoneum and in right iliac fossa (
Figs. 1,2). Menteric lymphadenopathy was prent. She underwent adhesiolysis,menteric lymph node biopsy, peritoneal toilet and mass
closure leaving an intraperitoneal drain. Post operative period was uneventful. She was discharged on 05 Oct 2003.Histopathology of menteric lymphnode revealed granulomatous lymphadenitis suggestive of tubercular origin.Histopathology of adhesive band revealed acute inflammation. She was put on anti-tubercular therapy viz. 2EHRZ+4HR wef 14 Oct 2003. She made an uneventful recovery.
Discussion
Abdominal cocoon is a rare dia, characterid by a thick fibrotic membrane that wraps the small bowel in a concertina-like fashion. Terms such as sclerosing peritonitis [2], encapsulating peritonitis [3] and sclerosing encapsulating peritonitis [4] have also been ud to describe this condition. A total of 35 cas have been reported, of which 25 were females and 10 males. Four of the female patients were children. Five cas have been reported from India. Last ca reported in India is by Kumar et al [5]. Foo et al [1] reported 10 abdominal cocoons within two years of menarche and retrograde menstruation has been incriminated as the cau of primary peritonitis. Some drugs espe
cially beta adrenergic blockers like practolol have been suggested as a possible cau. Eltringherm et al [2] reported nine cas undergoing practolol therapy who developed peritonitis causing sclerosing peritonitis. Holland [4]reported sclerosing peritonitis in patients on chronic ambulatory peritoneal dialysis. Dialysate solutions and bacterial peritonitis have been reported as aetiological factors but neither of the hypothesis are proven.Preoperative diagnosis of abdominal cocoon is difficult. Diagnosis is usually made at laparotomy and the suspicious clinical features are vomiting, pain abdomen, abdominal distention, the prence of a soft non-tender mass on palpation, and typical appearance on oral contrast studies, which shows delayed transit with a degree of intestinal obstruction. The small bowel
Abdominal Cocoon
Lt Col D Chopra, VSM *, Lt Col JN Lakhe +, Col SC Sharma #, Col KR Salgotra **,Brig MSVK Raju (Retd)++
MJAFI 2006; 62 : 282-283
Key Words: Abdominal cocoon; Intestinal obstruction
Abdominal Cocoon283
passage radiography may show sacculated small bowel[6]. Computed tomography scan abdomen can be of help in out lining the fibrotic membrane (Fig 3). The typical contrast enhanced computed tomography findings of an abdominal cocoon are an encapsulated clump of bowel, tethering of small bowel loops and loculated fluid collection with peritoneal thickening and calcification.
This condition should not be confud with peritoneal encapsulation, which is characterid by an accessory peritoneal sac enveloping the entire small bowel without being adherent to the intestine [7]. Peritoneal encapsulation is generally found accidentally and there are no symptoms. Surgical treatment consists of lys of the membrane and adhesions. Bowel rection is not necessary and clinical outcome is perfect.
Conrvative management of abdominal cocoon often fails. Surgery includes freeing the bowel from the thick encasing membrane and the relea of the obstruction. Finger disction is done with minimal blood loss. The bowel rosa is not injured at any stage. Extensive surgery and unnecessary bowel rection are associated with a high incidence of anastomotic failure and should be avoided.
莲子粥The ca we prent had underlying tuberculosis of menteric lymph nodes. Laloo et al [8] have reported abdominal cocoon with tubercular pelvic inflammatory dia.
The occurrence of abdominal cocoon with tuberculosis of menteric lymph nodes is an unusual association of two unrelated pathologies. Diminished resistance due to abdominal tuberculosis may have provoked an idiopathic acute inflammatory respon. Conflicts of Interest
None identified
References
励志词语2个字
1.Foo KT, Rauff A, Foong WC, Sinniah R. Unusual small
intestinal obstruction in adolescent girls: The abdominal cocoon.
Br J Surg 1978; 65: 427-30.
2.Eltrigham WK, Espinar HJ, Windsor CWU,et al. Sclerosing
peritonitis due to practolol: A ca report on 9 cas and their surgical management. Br J Surg 1977: 64: 229-35.
3.Verge C, Celicout B. Peritoneal permeability and encapsulating
peritonitis. Lancet 1985; 1: 986-7.
4.Holland P. Sclerosing encapsulating peritonitis in chronic
ambulatory peritoneal dialysis. Clin Radiol 1990; 41: 19-23.
5.Kumar M, Deb M, Prashad R. Abdominal cocoon: report of a
ca. Surg Today 2000; 30: 950-3.
西安休闲
6.Erham Hama Loglu, Husan Altar, Arif Ozdemiv, Ahmet Ozenc.
The Abdominal cocoon: A ca report. Digestive Surgery 2002;
19: 422-4.
欧美丝袜泰斗
7.Lewin K, Mc Carthy LJ. Peritoneal encapsulation of the small
intestine. Gastroenterology 1970; 59: 270-2.
8.Lalloo S, Krishna D, Maharajah J. Ca report: Abdominal
cocoon associated with tuberculous pelvic inflammatory dia.
Br J Radiol 2002; 75: 174-6.
Fig. 1 :Abdominal cocoon Fig. 2 :Abdominal cocoon Fig. 3 :
正反比例的概念
CT scan abdomen showing fibrotic membrane
MJAFI, Vol. 62, No. 3, 2006
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