|Year : 1984 | Volume
| Issue : 1 | Page : 62-3
Abdominal cocoon : an unusual intestinal obstruction (a case report).
MN Ahmed, SS Kaur, HU Zargar
M N Ahmed
|How to cite this article:|
Ahmed M N, Kaur S S, Zargar H U. Abdominal cocoon : an unusual intestinal obstruction (a case report). J Postgrad Med 1984;30:62-3
|How to cite this URL:|
Ahmed M N, Kaur S S, Zargar H U. Abdominal cocoon : an unusual intestinal obstruction (a case report). J Postgrad Med [serial online] 1984 [cited 2022 Jun 26 ];30:62-3
Available from: https://www.jpgmonline.com/text.asp?1984/30/1/62/5481
Though the knowledge of intestinal obstructions dates back to antiquity, it still remains a global surgical problem. Eighty per cent of cases with intestinal obstruction occur in the small bowel (Som, 1974) and is a common surgical emergency. Post-operative and inflammatory adhesions are the most commonly encountered causes of intestinal obstruction. Herein, we present a case of intestinal obstruction having unusual type of adhesions.
Z.A., a 16 year old young muslim girl was admitted in the emergency surgical services of S.M.H.S. Hospital, Srinagar, Kashmir (India) with complaints of colicky abdominal pain, vomiting and constipation of 4 days' duration. The patient was unmarried and had started menarche 2½ years ago. There was no history of peritonitis, abdominal surgery, prolonged drug intake or tuberculosis.
General physical examination revealed an anxious looking, averagely built patient having mild dehydration. Her pulse was 108/minute, temperature, 90°F and B.P., 100/68 mm Hg. There was no cyanosis, jaundice or lymphadenopathy; Systemic examination did not reveal any abnormality. Local examination of the abdomen revealed fullness in the lower abdomen with normal hernial sites. There was mild tenderness and rigidity in the whole of the lower abdomen especially in the hypogastrium. A vague mass, almost occupying the right illiac fossa, the hypogastrium and some parts of the left iliac fossa and umbilical regions was palpable. The mass was firm with indefinite margins having no mobility and slightly tender on deep palpation. Percussion revealed a tympanitic note over the swelling. There was no free fluid in the abdomen. The bowel sounds were exaggerated and high pitched. Per rectal examination was normal. Pregnancy and any swelling in connection with uterus were excluded by a gynaecological examination.
A provisional diagnosis of subacute intestinal obstruction with peritonitis was made. Routine investigations including haemogram, urine analysis and serum chemistry were all within normal limits. Skiagram of the chest was normal but plain X-ray of the abdomen (standing) showed multiple air-fluid levels, with no free gas under the dome of the diaphragm. After hydrating the patient, an exploratory laparotomy was performed. After opening the peritonium, caecum was not destended and no traces of small gut were seen from the duodenojejunal junction to ileocaecal region. Instead, a huge globular swelling was occupying the central abdomen. This swelling was having a thick fibrous covering and was freely mobile being free from the parietal peritoneum. While tracing and searching for the rest of the gut from the duodenojejunal flexure onwards, the membrane encasing the mass got ruptured at a place and exposed the coils of intestine. The membrane now, could be incised and peeled off easily. The small gut within this membrane was seen coiled up in a concertina-like fashion and these coils could be separated easily from each other with the intestinal serosa intact. Thus the small gut was left free and followed from duodenojejunal flexure to ileocaecal junction and freed from the encasing fibrous bag-like membrane. The whole freed small gut was viable and thus no more surgical procedure was deemed desirable. The peeled off membrane was studied histopathologically. The patient had an uneventful postoperative period and was discharged from the hospital on the 10th post-operative day. She has been regularly attending our follow-up clinics for the last 1½ years and is symptom-free.
The histopathological study of the membrane revealed nonspecific chronic inflammatory changes.
The causes of intestinal obstruction differ very little from one part of the globe to another. Kochhar et al (1966) reported external hernias, volvulus, tuberculosis and post-operative or inflammatory adhesions as the most common causes of intestinal obstruction in India. Adhesion formation causing intestinal obstruction is a very important and frequently observed pathology.
The case reported by us is peculiar and presented with unusual type of adhesions. The aetiopathogenesis of such cases appears obscure. Brown et al (1974), Windsor et al (1975) and Eltringham et al (1977) reported similar cases due to sclerosing peritonitis in patients on long term practolol, a beta-adrenergic blocker. Recently, Foo et al (1978) reported 10 such cases in whom they could not find any cause for this peculiar type of peritonitis producing intestinal obstruction and they, for the first time, grouped this condition as a new clinical entity "the abdominal cocoon". Because of the peculiar age and sex distribution of the disease, they postulated that the condition is due to retrograde menstruation with subclinical, viral peritonitis resulting in the development of an encapsulating membrane on the intestine. The present case also falls in the same narrow age group within a few years of menarche in whom no other cause could be found responsible for the plastic type of peritonitis and the hypothesis given by Foo et al (1978) may be the only explanation for such a case. This condition, "the abdominal cocoon", should be suspected in young adolescent girls who present with small intestinal obstruction with no obvious cause.
|1||Brown, P., Baddeley, H., Read, A. E., Davies, J. D. and McGarry, J.: Sclerosing peritonitis-an unusual reaction to a beta adrenergic blocking drug (Practolol). Lancet, 2: 1477-1481, 1974.|
|2||Eltringham, W. K., Espiner, H. J., Windsor, C. W. O., Griffiths, D. A., Davies, J. D., Baddeley, H., Read, A. E. A. and Blunt, R. J.: Sclerosing peritonitis due to Practolol: A report on 9 cases and their surgical management. Brit. J. Surg., 64: 229-235, 1977. |
|3||3. Foo, K. T., Ng. K. C., Rauff, A., Foong, W. C. and Sinniah, R.: Unusual small intestinal obstruction in adolescent girls: the abdominal cocoon. Brit. J. Surg., 65: 427-430, 1978.|
|4||Kochhar, K. S., Rai, H. and Singh, H.: The management of acute intestinal obstruction-a critical review of 238 cases. Ind. J. burg., 28: 553-564, 1966.|
|5||Som, A. L.: "Principles and Practice of Modern Surgery." 3rd Edition, 30, Jawaharlal Nehru Road, Calcutta-16, 1974, p. 384.|
|6||Windsor, C. W. O., Kurrein, F. and Dyer, N. H.: Fibrinous peritonitis--a complication of Practolol therapy. Brit. Med. J., 2: 68, 1975.|