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Case Report |
1 Department of Diagnostic Radiology, Yonsei University College of Medicine,
Research Institute of Radiological Science, Yongdong Severance Hospital
#146-92, Dogok-Dong, Kangnam-Gu, Seoul 135-270, South Korea.
2 Department of Diagnostic Radiology, Yonsei University College of Medicine,
Research Institute of Radiological Science, 134 Shinchon-dong, Seodaemoon-Ku,
Seoul 120-752, South Korea.
Received June 10, 2003;
accepted after revision July 29, 2003.
Address correspondence to K. W. Kim.
Introduction
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We report two cases of abdominal cocoon, show the CT and barium features of this unusual entity, and discuss the preoperative diagnostic clues obtained by radiologic imaging and pathologic correlation.
A 34-year-old woman was admitted to our hospital with a 1-day history of vomiting and left lower abdominal pain. She had experienced several similar episodes over the previous 10 years, but she had received no specific treatment because of spontaneous symptomatic relief. She had no contributory history, such as practolol use, hepatic disease, tuberculosis, or abdominal surgery. Findings of laboratory studies were normal.
A radiograph of the abdomen showed an intermittently dilated small bowel. Abdominal sonography showed a large echogenic mass associated with a small amount of ascites in the left lower abdomen (Fig. 1A). Contrast-enhanced CT of the abdomen performed on the same day showed the clustered gas-containing small-bowel loop within a thick membranelike sac and dilated proximal small bowel with air–fluid levels due to intestinal obstruction (Fig. 1B). A small amount of ascites was seen in the left inguinal fossa. A small-bowel follow-through performed on the fourth day after admission revealed that the ileal loops were bunched and confined in the lower abdomen and pelvic cavity and that these gave rise to an extrinsic mass effect on the adjacent small-bowel loops (Fig. 1C).
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Exploratory laparotomy was performed on the seventh hospital day. At surgery, it was found that a considerable length of the distal small bowel, 30 cm from the ileocecal valve, was encased in a whitish thickened membrane. The sigmoid colon was displaced to the left, and the greater omentum looked hypoplastic and was also encased in a fibrous tissue. The histology of the membrane revealed only fibrosis without inflammation. After the operation, the patient experienced bowel frequency and loose stool for about 6 months, both of which were controllable by medication.
A second case in a 47-year-old man with similar history and imaging findings was also encountered (Fig. 2A, 2B).
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TopIntroductionDiscussionReferences |
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The cause and pathogenesis of the condition have not been elucidated. A history of previous abdominal surgery or peritonitis, chronic ambulatory peritoneal dialysis, and the prolonged use of practolol have been implicated as causative factors [1–4].
Yip and Lee [5] listed four main clinical features that help identify abdominal cocoon preoperatively. These features are its occurrence in a relatively young girl without an obvious cause of intestinal obstruction, a history of similar episodes that resolved spontaneously, a presentation with abdominal pain and vomiting but rarely the four cardinal symptoms of intestinal obstruction, and the presence of a nontender soft mass on abdominal palpation.
The preoperative diagnosis of abdominal cocoon is difficult because of its nonspecific imaging findings, and reports are few in the literature on its radiologic imaging findings.
Sieck et al. [6] reported that a "cauliflower sign" on a contrast study of the small intestine is diagnostic. However, Maguire et al. [7] reported that the cauliflower sign is unpredictable. They suggested that delayed transit by a small-intestine contrast study is more diagnostic.
In our two patients, barium meal finding showed a fixed cluster of dilated small-bowel loops lying in a concertinalike fashion, which had also been described by Sieck et al. [6]. However, small-bowel transit time was not delayed in our two patients.
The ability of CT to depict the cause of a small-bowel obstruction, with a sensitivity of 73–95% for high-grade small-bowel obstruction [8], makes it an important diagnostic tool, but few have reported CT findings of abdominal cocoon [2, 7, 9].
Maguire et al. [7] reported that gross ascites with small-bowel intestine loops congregated in a single area in the peritoneal cavity are typical findings of abdominal cocoon on an abdominal CT scan. Wig and Gupta [9] reported that the typical finding of abdominal cocoon on CT is a concentration of the whole small bowel to the center of the abdomen encased by a soft tissue–density mantle. Other CT features of abdominal cocoon include signs of obstruction, agglutination and the fixation of intestinal loops, mural thickening, ascites and localized fluid collections, peritoneal thickening and enhancement, peritoneal or mural calcifications, and reactive adenopathy [2].
In our two patients, the CT findings were similar and involved a clustering of small-bowel loops encased by a thin membranelike sac. This finding has been described by several reports as one of the typical findings in patients with abdominal cocoon [2, 7, 9]. In our first patient, a small amount of ascites was seen in the left inguinal fossa. However, ascites was not seen in our second patient. Hollman et al. [4] described characteristic sonographic findings with changes of peristalsis, tethering of the bowel to the posterior abdominal wall, intraperitoneal echogenic strands, and membrane formation during the late stage of the disease. We studied only one case on abdominal sonography. In this case, abdominal sonography showed a large echogenic mass associated with a small amount of ascites in the left lower abdomen. However, membrane formation was not observed.
The histology of the membrane, which was submitted for examination in both cases, revealed thickened fibrocollagenous tissue, with or without foci of inflammation, and a thin encapsulating membrane, which was observed in both cases on CT scan. Thus, this correlates histopathologically to thickened fibrocollagenous tissue.
In conclusion, we suggest that clustered small-bowel loops encased by a thin membranelike sac on CT and a concertina pattern or a cauliflower sign on barium small-bowel series provide a clue to the diagnosis of abdominal cocoon.
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