Trapped in the Cocoon: A Rare Case of Small Bowel Obstruction

Abstract

Introduction: Abdominal cocoon syndrome (ACS), or encapsulating peritoneal sclerosis (EPS), is a rare cause of small bowel obstruction characterized by fibrous encapsulation of the intestines. Its nonspecific clinical and radiological presentation makes it easily overlooked and delayed diagnosis can lead to significant worse patient outcomes. This case report aims to raise clinical awareness of ACS and underscore the importance of maintaining a high index of suspicion in patients presenting with small bowel obstruction. Case Presentation: A 58-year-old male presented with clinical signs of complete small bowel obstruction. CT imaging revealed clustered small bowel loops within a sac-like structure. Exploratory laparotomy, performed for abdominal cocoon with small bowel obstruction, demonstrated that the small bowel was encased in a thick fibrocollagenous membrane with dense adhesions, without evidence of ischemia. Adhesiolysis was successfully performed to release the trapped bowel. Histopathology confirmed EPS without evidence of malignancy or tuberculosis. The patient remained asymptomatic at one-year follow-up. Discussion: Preoperative diagnosis of the ACS remains challenging due to its uncertain clinical and radiological presentation. Although CT imaging may suggest the condition through characteristic findings, definitive diagnosis is typically made intraoperatively. Surgical excision of the fibrous membrane with meticulous adhesiolysis remains the treatment of choice, as non-operative management is rarely successful. Timely surgical intervention is key to preserve bowel viability and improve patient’s outcomes. Histopathologic evaluation is essential for diagnosis with subsequent management guided by the histopathologic findings. Conclusion: Abdominal cocoon syndrome (ACS) is a rare but clinically significant cause of small bowel obstruction. Its characteristic findings from CT imaging plays a crucial role in preoperative diagnosis while early recognition and prompt surgical intervention with meticulous adhesiolysis resulted in complete resolution of obstruction and satisfactory outcomes.