# Unraveling the cocoon: A case report on preoperative ambiguity and definitive surgical management of encapsulating peritoneal sclerosis

## TL;DR

This case report describes a rare condition called sclerosing encapsulating peritonitis, its diagnostic challenges, and surgical treatment in a 49-year-old woman.

## Contribution

The paper presents a detailed case report and review of 14 published cases, emphasizing laparotomy as the gold standard for diagnosis and treatment.

## Key findings

- SEP is diagnosed definitively through laparotomy despite CT/MRI aiding suspicion.
- Surgical treatment involves membrane excision and adhesiolysis to prevent complications.
- Histopathology reveals fibrous encapsulation and chronic active colitis in SEP cases.

## Abstract

Abdominal cocoon, or sclerosing encapsulating peritonitis (SEP), is a rare condition characterized by a fibrocollagenous membrane encasing the intestines, often leading to obstruction. First described in 1907, its etiology remains unclear, with primary (idiopathic) and secondary forms linked to prior surgeries, infections, or systemic diseases. Preoperative diagnosis remains challenging due to nonspecific symptoms.

A 49-year-old female presented with abdominal pain, vomiting, and constipation. Imaging revealed dilated bowel loops and adhesions. Exploratory laparotomy confirmed SEP, with histopathology showing chronic active colitis and fibrous peritoneum. Adhesiolysis and loop ileostomy were performed, with the patient discharged in stable condition.

SEP is classified into three anatomical types, with idiopathic cases often lacking identifiable risk factors. Diagnostic imaging (CT/MRI) aids suspicion, but definitive diagnosis typically requires laparotomy. The condition must be differentiated from peritoneal encapsulation, a distinct entity. Management depends on severity, ranging from membrane excision to bowel resection. A review of 14 published cases highlights laparotomy as the gold standard for both diagnosis and treatment, though laparoscopic approaches are emerging.

SEP remains a diagnostic dilemma, necessitating high clinical suspicion in cases of unexplained obstruction. Surgical intervention is often curative, but meticulous technique is vital to avoid complications. Further research into biomarkers and minimally invasive diagnostic tools is warranted.

•CT imaging aids preoperative suspicion but diagnosis requires laparotomy.•A cocoon abdomen presents with bowel obstruction and nonspecific symptoms.•Membrane excision and adhesiolysis remain the mainstay of surgical treatment.•Histopathology confirms fibrous encapsulation with chronic active colitis.•Early intervention prevents complications like bowel necrosis and sepsis.

CT imaging aids preoperative suspicion but diagnosis requires laparotomy.

A cocoon abdomen presents with bowel obstruction and nonspecific symptoms.

Membrane excision and adhesiolysis remain the mainstay of surgical treatment.

Histopathology confirms fibrous encapsulation with chronic active colitis.

Early intervention prevents complications like bowel necrosis and sepsis.