Idiopathic sclerosing encapsulating peritonitis (or abdominal cocoon)

A 56 year-old man presented in A&E department with small bowel ileus. He had a history of 6 similar episodes of small bowel obstruction in the past 4 years, which resolved with conservative treatment. Pre-operative work-up did not reveal any specific etiology. At laparotomy, a fibrous capsule was revealed, in which small bowel loops were encased, with the presence of interloop adhesions. A diagnosis of abdominal cocoon was established and extensive adhesiolysis was performed. The patient had an uneventful recovery and follow-up.Idiopathic sclerosing encapsulating peritonitis, although rare, may be the cause of a common surgical emergency such as small bowel ileus, especially in cases with attacks of non-strangulating obstruction in the same individual. A high index of clinical suspicion may be generated by the recurrent character of small bowel ileus combined with relevant imaging findings and lack of other plausible etiologies. Clinicians must rigorously pursue a preoperative diagnosis, as it may prevent a "surprise" upon laparotomy and result in proper management.Sclerosing encapsulating peritonitis is a rare cause of small bowel obstruction, and can be classified as idiopathic or secondary (most importantly and most frequently due to chronic ambulatory peritoneal dialysis). The idiopathic form (also known as abdominal cocoon) was first described by Foo et al in 1978[1,2]. It affects mainly young females from tropical and subtropical regions, but adult case reports from temperate zones can be encountered in literature. It is characterized by a thick, fibrotic, cocoon-like membrane, partially or totally encasing the small bowel. Clinically, it presents with recurrent episodes of acute or subacute small bowel obstruction, weight loss, nausea and anorexia, and at times with a palpable abdominal mass[2]. Most cases are diagnosed incidentally at laparotomy, as in the case presented, although a preoperative diagnosis is purported feasible by a combination of barium foll