Abdominal Tuberculosis With a Cocoon

Abdominal cocoon or sclerosing encapsulating peritonitis is a rare condition of unknown cause in which intestinal obstruction results from the encasement of variable lengths of bowel by a dense fibrocollagenous membrane that gives the appearance of a cocoon. This condition is not often suspected preoperatively, and therefore the diagnosis is usually made at laparotomy (1). The abdominal cocoon was first described by Owtschinnikow in 1907 as “peritonitis chronica fibrosa incapsulata” (2). A 30 year old male presented with pain left lower abdomen and vomiting of 3 days duration. He had similar episodes of pain and vomiting in the past that were managed conservatively, with a diagnosis of subacute intestinal obstruction (SAIO). On examination he was thin built and looked undernourished. His vitals were normal and he had mild pallor with Hb of 10.9 with no lymphadenopathy. Abdomen was distended, with a sausage shaped intra-abdominal lump felt in left umbilical region, size 6x4cm, with concavity towards midline. Margins of the lump were ill defined, soft in consistency, non-pulsatile, mobile. Bowel sounds were not present and there was no shifting dullness. Hernial sites and per rectal examination was normal. The patient had no previous history of hepatic disease, abdominal surgery, peritoneal dialysis, ventriculoperitoneal and peritoneovenous shunting. Additionally, no clinical features of connective tissue disease could be identified. A family history of chest tuberculosis was, however, positive. Plain radiograph abdomen showed multiple air and fluid levels in the erect position. Chest radiographs were however normal without any evidence of pulmonary tuberculosis. Ultrasound abdomen showed gas filled loops of small bowel, suggestive of small bowel loop obstruction. A CECT (contrast enhanced computed tomography) abdomen showed gut wall thickening (Figure 1) Diagnosis of acute intestinal obstruction was made. Exploratory laparotomy was done. The whole of small bowel was adhered together like a cocoon (Figure 2 and 3) from the duodeno-jejunal flexure to the ileo-caecal region, encapsulated within a peritoneal membrane with adhesions which were broken and the thick membrane was resected. Mesenteric Lymphadenopathy was noted. Histology of the membrane revealed caseating granuloma and giant cells with mild fibrosis and nodal microscopy revealed same features. A diagnosis of abdominal cocoon secondary to abdominal tuberculosis was suspected. Postoperatively, the patient was initiated