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Gut. 2007 April; 56(4): 592.
PMCID: PMC1856845

EDITOR'S QUIZ: GI SNAPSHOT

Answer

From the question on page 575

The CT scan (fig 1A,B1A,B in Questions section) revealed multiple adherent small bowel loops encased within a thickened enhancing peritoneal membrane (arrow) forming a sac‐like structure, with localised fluid collection seen within this sac, features suggestive of an abdominal cocoon. The second and third parts of the duodenum were dilated (arrow) as far as and at the site of entry into the encapsulated sac‐like structure. Peritoneum and omentum thickening (arrows) was also noted (fig 1C1C in Questions section). There was no ascites or lymphadenopathy. The liver, spleen, kidneys and pancreas were normal. A radiological diagnosis of sclerosing encapsulating peritonitis forming an abdominal cocoon was made, which was later confirmed at surgery.

figure gt86561a.f1
Figure 1 A photomicrograph (H&E) showing many malignant cells (arrows) surrounded by stroma and inflammatory cells. Inset: immunostaining for cytokeratin showing abundant malignant cells.

Sections from gastric serosa showed fibrocollagenous tissue with multiple nodular and discretely scattered malignant cells (fig 11,, arrows). UGI biopsy from the gastric ulcer revealed poorly differentiated adenocarcinoma.

Abdominal cocoon, also referred to as sclerosing encapsulating peritonitis, is a rare condition characterised by fibrotic encapsulation of the bowel. The exact aetiology is unclear but has been previously described as a benign process in patients with a history of previous abdominal surgery or peritonitis, liver transplant, chronic ambulatory peritoneal dialysis, or prolonged use of the β‐blocker practolol, and in patients with tuberculous pelvic inflammatory disease. Clinical presentation includes abdominal distension, acute intestinal obstruction and a palpable abdominal mass.

We describe a case of disseminated gastric adenocarcinoma (signet cell carcinoma) as a rare cause of abdominal cocoon.

Preoperative diagnosis is a challenge and diagnosis is usual made at laparotomy.

CT scan provides a more accurate diagnosis of this entity as well as its complications, and may also help to exclude other causes of intestinal obstruction.


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