Case Presentation:

A 58 year old gentleman  with no known past medical or surgical history, or history of smoking or alcohol intake, presented to the ED with abdominal pain, nausea, vomiting ,constipation with generalized weakness . He had significant weight loss of 60 lbs in last 6 months. On examination he was cachectic with gross ascites and a hard tender mass just below umbilicus. CT scan of abdomen was done which showed clumping of small bowel together with marked ascites along with small and nodular liver consistent with cirrhosis Paracentesis was done which showed exudative ascites with benign cytology and negative cultures. Liver biopsy was done which showed stage 1 liver fibrosis. On laparoscopic evaluation significant encasement of small bowel loops by thick fibrous membrane was noted. Biopsy of peritoneal lining showed fragments of dense fibro collagenous tissue with scattered mild chronic lymphocytic inflammatory cell with no malignant or granulomatous cells. This was consistent with sclerosing peritonitis. Serological marker including IG4 antibody was negative. Colonoscopy showed a mass in the proximal ascending colon consistent with carcinoma and biopsy from the mass showed poorly differentiated adenocarcinoma with signet cells. His condition progressively worsened and family decided to enroll him into hospice care. Patient died after 6 months

Discussion:

Abdominal Cocoon, also known as sclerosing encapsulating peritonitis (SEP) is a disease entity with thick fibrous membrane encasing the small bowel into a lump presenting as acute or sub-acute intestinal obstruction. SEP itself is a rare manifestation, with prevalence rates between 0.54% and 0.9%.  Its pathophysiology is not so clear but known associations are patients undergoing peritoneal dialysis, abdominal tuberculosis, history of intra-abdominal surgeries, IG4 related fibrosis. Some literature suggests that it can be associated with intra-abdominal malignancy. The most common presenting symptoms are abdominal pain, diarrhea, and weight loss or asymptomatic. Diagnosis is usually made by CT scan followed by laparoscopy and biopsy.  Treatment is usually steroids or surgery however it is not curative.

Conclusions:

Sclerosing encapsulated peritonitis can be one of the initial presentation or paraneoplastic syndrome associated with adenocarcinoma of colon. So, though rare one should always search for colonic malignancy in any case of small bowel obstruction with features suggestive of sclerosing encapsulated peritonitis. To our knowledge this is the first case report of abdominal cocoon associated with signet ring cell adenocarcinoma of colon.