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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 3  |  Page : 242-244

Abdominal cocoon: Classic computed tomography images


1 Department of Radio-diagnosis, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
2 Department of Radio-diagnosis, Government Medical College, Jammu, Jammu and Kashmir, India

Date of Web Publication17-Jul-2018

Correspondence Address:
Mohd Ilyas
Department of Radio-diagnosis, Sher-I-Kashmir Institute of Medical Sciences, Srinagar - 190 011, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_20_18

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  Abstract 


Abdominal cocoon is an uncommon cause of acute or subacute intestinal obstruction mostly secondary to tuberculosis. This report highlights the classic imaging features on computed tomography in a case of ileocecal tuberculosis with secondary abdominal cocoon.

Keywords: Abdominal cocoon, computed tomography, sclerosing peritonitis, tuberculosis


How to cite this article:
Ilyas M, Bhat TA, Ganaie KH, Gojwari T. Abdominal cocoon: Classic computed tomography images. CHRISMED J Health Res 2018;5:242-4

How to cite this URL:
Ilyas M, Bhat TA, Ganaie KH, Gojwari T. Abdominal cocoon: Classic computed tomography images. CHRISMED J Health Res [serial online] 2018 [cited 2019 Oct 21];5:242-4. Available from: http://www.cjhr.org/text.asp?2018/5/3/242/236889




  Introduction Top


Abdominal cocoon refers to encasement of bowel loops with acute or subacute intestinal obstruction due to abnormal thickening of the peritoneum in severe cases of sclerosing peritonitis.[1]


  Case Report Top


A 42-year-old male, nonalcoholic and nonsmoker, patient presented to the Internal Medicine with the complaints of dull-aching abdominal pain for the past 3–4 months, and breathlessness with evening rise of temperature for the past 1 month. He had lost 5 kg weight in past 1 month. His history was significant for being a defaulter of treatment for pulmonary tuberculosis 1 year back. He had taken medication for 1 month only. There was no history of constipation. His Blood pressure was 124/80 mmHg, temperature – 99.7°F, breath rate – 16/min, and a pulse of 78 beats/min.

The clinical examination was positive for stony dullness on palpation over the left half of chest and decreased breath sounds on the left side on auscultation. Chest ultrasonography revealed moderate left-sided pleural effusion. Cytological analysis of aspirated pleural fluid revealed raised pleural lymphocytes (82%), raised pleural white blood cell count (4560 × 109/l), and raised pleural ADA levels (350 U/L). His hemoglobin was 12 g%. His renal function tests and liver function tests were as normal. The patient was HIV negative.

A contrast-enhanced (oral and intravenous) computed tomographic scan of the chest was performed using 128-slice dual-source dual-energy computed tomography (CT) scanner (Siemens Healthcare, Germany). As shown in [Figure 1], the study revealed moderate left-sided pleural effusion. Abdominal scan revealed an inflammatory enhancing mass involving the ileocecal region [Figure 2]. The most important finding of the CT was that the peritoneum was smoothly thickened with homogeneous enhancement (sclerosing peritonitis) encasing the mildly dilated small bowel loops giving it the classic appearance of abdominal cocoon [Figure 3], [Figure 4], [Figure 5]. The fine-needle aspiration cytology (FNAC) of the ileocecal mass revealed the tubercular caseating granulomas.
Figure 1: Axial computed tomography image along the lower chest showing moderate left-sided pleural effusion (white dot)

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Figure 2: Coronal abdominal computed tomography image (postcontrast) showing the inflammatory mass in ileocecal region (yellow arrow) and smoothly thickened and enhancing peritoneum (white arrows)

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Figure 3: Axial abdominal computed tomography image showing encasement of small bowel loops (asterisk) by a smoothly thickened and enhancing peritoneum (white arrows) giving it a shape of a cocoon

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Figure 4: Coronal reformation of abdominal computed tomography image showing the classic cocoon appearance with thickened peritoneum (white arrows) encasing the small bowel loops (asterisk)

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Figure 5: Coronal reformation after oral contrast showing the classic abdominal cocoon and the passage of oral contrast material in the small bowel loops indicating peristalsis

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Thus, with the evidence of pleural fluid analysis, ileocecal FNAC analysis, and computed tomographic findings, the diagnosis of pleural and abdominal tuberculosis was finalized with features of sclerosing peritonitis forming classic abdominal cocoon secondary to abdominal tuberculosis.

The pleural effusion was drained by the intercostal tube drainage. The patient was treated for pleural and extrapulmonary tuberculosis. The patient was started with standard 4-drug (HRZE) anti-tubercular therapy (ATT) for 9 months. The patient and his relatives were advised to keep a check on strict adherence to therapy for appropriate results. The patient was followed monthly with liver function tests. The check CT scan at 4 months after treatment revealed resolution of the features of ileocaecal mass and sclerosing peritonitis (abdominal cocoon).


  Discussion Top


Although it can also be described on ultrasonography, CT forms the most sensitive investigation for the diagnosis. The CT features include smooth thickening and enhancement of the peritoneum. With the advancement of the disease process, there occurs encapsulation of the bowel resulting in bowel obstruction. Advanced encapsulating peritonitis is usually associated with calcifications although severe encapsulation may occur even in the absence of calcifications.[1] In continuous ambulatory peritoneal dialysis-associated sclerosis, it may also result in the formation of loculated collections consisting of peritoneal dialysate.[2]

The differential diagnosis includes tuberculosis, amyloidosis, hyperparathyroidism, pseudomyxoma peritonei, and peritoneal carcinomatosis. Internal hernia can also mimic the CT features of sclerosing peritonitis which can produce clustering of bowel loops.[2]

Although surgery can be done in patients with severe signs of obstruction, there is evidence that conservative management with ATT helps in resolution of symptoms and avoid surgery.[3]


  Conclusion Top


CT forms the most sensitive imaging modality for exact delineation of the abdominal cocoon with the ability to rule out other causes of intestinal obstruction. The abdominal cocoon can be managed conservatively by administration of ATT.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
George V, Tammisetti VS, Surabhi VR, Shanbhogue AK. Chronic fibrosing conditions in abdominal imaging. Radiographics 2013;33:1053-80.  Back to cited text no. 1
    
2.
Ti JP, Al-Aradi A, Conlon PJ, Lee MJ, Morrin MM. Imaging features of encapsulating peritoneal sclerosis in continuous ambulatory peritoneal dialysis patients. AJR Am J Roentgenol 2010;195:W50-4.  Back to cited text no. 2
    
3.
Sharma V, Mandavdhare HS, Rana SS, Singh H, Kumar A, Gupta R, et al. Role of conservative management in tubercular abdominal cocoon: A case series. Infection 2017;45:601-6.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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