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Hôtel Dieu de France Beirut, Lebanon
Abdominal cocoon is a well-known but rare cause of small-bowel obstruction in which all or part of the small bowel is encased by a fibrous capsule, giving the appearance of a cocoon. Approximately 70 cases have been reported in the literature. The diagnosis is rarely made preoperatively. To our knowledge, MRI features have never been reported.
A 40-year-old man was hospitalized for lower abdominal pain, nausea, vomiting, and abdominal distention occurring intermittently over the past 5 years and increasing in frequency. Abdominal sonography, colonoscopy, and gastroscopy were normal. Blood analyses were unremarkable.
A barium meal and follow through revealed a dilated jejunum proximal to ileal loops that were agglomerated in a concertina-like fashion (Fig. 2A). The colon was normal and the distal ileal loop was identified. CT revealed a diffuse dilatation of the small-bowel loops proximal to the jejunoileal junction. Ileal loops were also dilated and agglomerated in a concertina-like fashion; a linear dense structure was seen encircling the bowel loops (Fig. 2B).
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Because we were not aware of this disease and for further evaluation of the peritoneal space and small-bowel wall, MRI was performed on a 1.5-T Signa Infinity (GE Healthcare). The linear dense structure was also visualized on MRI (Fig. 2C), and a coronal section (Fig. 2D) revealed the same pattern as the barium study. At laparotomy, the proximal bowel loops were dilated but normal; the distal loops were encapsulated in a whitish, thick membrane. After this capsule was incised, the bowel loops were easily freed and had a normal appearance. On histologic examination, the membrane was found to be composed of fibrous tissue with mononuclear inflammatory cells.
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On barium studies, a cauliflower appearance or concertina-like pattern seen in our case has been reported by several authors [2]. It corresponds to the clustering of otherwise normal small-bowel loops. This finding was also evident on the coronal MRI section. CT was performed in a few cases. CT not only displays crowding of the small-bowel loops just as the barium study does, but it may also show the soft-tissue capsule encircling the bowel loops [2-4]. These findings were also seen on MRI.
In conclusion, except for anecdotal reports, the majority of cases of sclerosing peritonitis are still diagnosed at surgery. On barium studies, this entity must be suspected when a concertina-like or cauliflower pattern is seen. On CT, a fibrous capsule encircling the bowel loops is highly suggestive. MRI can display both findings. More thorough knowledge by radiologists of these findings on barium studies; CT; and, now, MRI must result in more frequent preoperative diagnoses based on one or two of these techniques.
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  N A Ibrahim and M A Oludara Abdominal cocoon in an adolescent male patient Trop Doct, October 1, 2009; 39(4): 254 - 256. [Abstract] [Full Text] [PDF]
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