The abdominal cocoon syndrome is described as a rare entity in which part or whole of the small bowel is enclosed in a fibrous membrane. This case report is of a 35 years old woman who had a provisional diagnosis of ovarian cyst. Intraoperatively she was found to have abdominal cocoon syndrome. Laparotomy with cystectomy was done. She developed subacute intestinal obstruction 5 days later. This was managed conservatively.

1. Ovarian cyst and abdominal cocoon syndrome

2. Apollo Medicine 2012 September
Volume 9, Number 3; pp. 249e251 Case Report
Ovarian cyst and abdominal cocoon syndrome
P. Lakshmi Reddy*, Satyamvada Pandey
ABSTRACT
The abdominal cocoon syndrome is described as a rare entity in which part or whole of the small bowel is enclosed in
a fibrous membrane. This case report is of a 35 years old woman who had a provisional diagnosis of ovarian cyst.
Intraoperatively she was found to have abdominal cocoon syndrome. Laparotomy with cystectomy was done. She
developed subacute intestinal obstruction 5 days later. This was managed conservatively.
Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
Keywords: Abdomen, Ovarian cyst, Cocoon, Sclerosing encapsulating peritonitis
CASE REPORT
A 35-year-old lady was admitted with a right ovarian cyst
and left hydrosalpinx on routine health check up. She was
planned for a diagnostic laparoscopy. She gave a history
of irritable bowel syndrome since 5 years. She had no
bladder, bowel complaints at presentation. There was no
history of acute pain abdomen or menstrual complaints or
of other medical illnesses or any surgeries earlier.
Patient was clinically stable. Local examination of the
abdomen revealed a soft abdomen with normal bowel
sounds and minimal tenderness in the right iliac fossa.
There was no guarding or rigidity and no organomegaly.
Pelvic examination was deferred as she was unmarried.
Routine laboratory work up was within normal limits.
Ultrasound of abdomen showed a bulky uterus with
a 9 cm right ovarian cyst with no septa or internal echoes.
Left hydrosalpinx was 6 cm in size.
Under a provisional clinical diagnosis of right ovarian
cyst with left hydrosalpinx, a diagnostic laparoscopy was
planned. Laparoscopy had to be abandoned because pneu-moperitoneum
could not be created; the parietal peritoneum
was seen loosely adherent to bowel and omentum like
a flimsy membrane. Laparotomy was done and confirmed
the same. A diagnosis of cocoon syndrome was made.
There was a thin walled cyst about 12 cm in diameter
covered by bowel by thin adhesions. Blood stained fluid
was drained and sent for cytology. Cyst wall was excised
and sent for histopathological examination. Right ovary
was seen at the base of the cyst and looked normal. Right
Department of Obstetrics and Gynecology, Apollo Hospitals, Jubilee Hills, Hyderabad, India.
* Corresponding author. email: plmmreddy@yahoo.com
Received: 31.5.2012; Accepted: 30.6.2012; Available online: 7.7.2012
Copyright 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2012.06.011

3. 250 Apollo Medicine 2012 September; Vol. 9, No. 3 Reddy and Pandey
tube was dilated. Retort shaped left hydrosalpinx was
noted. Left salpingectomy was done and tube sent for histo-pathological
examination. Left ovary was buried under
adhesions and could not be visualized. Reports revealed
benign cystic lesion with no significant abnormality. AFB
staining yielded negative results.
Her postoperative period was uneventful and she was
discharged from the hospital on the 3rd postoperative day.
Patient again presented to emergency room 2 days after
discharge with frequent vomiting. She also gave a history
of nausea and acidity, and occasional mild spasmodic
pain since last 2 days. There were no urinary symptoms,
hematemesis, blood in stools, fever, constipation or loose
motions. She gave a history of similar episodes twice in
childhood in winter months and was then managed
conservatively.
Physical examination revealed no signs of dehydration.
Vitals were stable. Abdomen was soft with mild tenderness,
mild gaseous distension and no organomegaly. Bowel
sounds were sluggish. X-ray erect abdomen showed
multiple air fluid levels in small bowel suggestive of small
bowel obstruction. USG abdomen was done and revealed
dilated small bowel loops with food particles and sluggish
particles, suggestive of subacute intestinal obstruction.
She was reviewed by a surgeon and a diagnosis of subacute
intestinal obstruction was confirmed.
She was managed conservatively with intravenous
fluids, kept nil by mouth, daily serum electrolytes were
monitored and replaced as required. She was continued
on antispasmodics, antacids and strict intake output was
charted. Total parenteral nutrition had to be started on the
6th day of hospital stay. She gradually improved with no
vomiting and was able to pass flatus. She tolerated clear
liquids from 8th day, and semisolid diet from 10th day.
She received dietary advice from a dietician.
She was discharged on the 10th day and was advised to
avoid dairy products. She has been on regular follow-ups
for the last 4 months and has been free of bowel symptoms
throughout this period.
DISCUSSION
Abdominal cocoon is a rare condition. It has been described
in literature as sclerosing encapsulating peritonitis.1 It is
characterized by partial or complete encasement of small
bowel by a thick ring of fibrous tissue and adhesions result-ing
in clumping of bowel loops.
The condition usually affects adolescent girls ranging
from 6 to 18 years, mostly in tropical regions.2 The exact
etiology is still not clear.
The condition has been classified as primary (idiopathic)
and secondary when it has a definite cause. Foo et al re-ported
this condition in 10 young girls 2 years after
menarche. They presented with bowel obstruction probably
caused by chemical peritonitis due to retrograde menstrua-tion.
3 Several other hypotheses suggest retrograde perito-nitis
via fallopian tube and damage by cell mediated
immunity incited by pelvic infection as causes.
Secondary causes include placement of peritoneovenous
shunts for refractory ascites, continuous ambulatory perito-neal
dialysis, systemic lupus erythematosus and use of
povidone iodine for abdominal wash and beta-adrenergic
blocker, practolol.4e7
Clinically patients report with features of recurrent acute
or chronic small bowel obstruction due to compression of
intestines within the constricting cocoon.3,4,8 An abdominal
mass may also be seen due to encapsulated and dilated
small bowel loops.
Preoperative diagnosis is rarely made. Laboratory and
radiological studies are nonspecific, they may suggest intes-tinal
obstruction. Ultrasound is usually inconclusive, or
shows only a vague clump of bowel loops with relative
fixity and echogenic peritoneal membrane. Preoperative
barium meal showed characteristic serpentine configuration
of dilated small bowel loops within the cocoon.8
Using CT, a preoperative diagnosis of abdominal cocoon
is more likely. Imaging features are, however not pathogno-monic.
9 CECT would reveal congregated small gut loops
confined to a single area and encased in a thick membrane
with a dilated proximal small intestine and gradual narrow-ing
of the distal ileum with obstruction.10

4. Abdominal cocoon syndrome Case Report 251
The final diagnosis of abdominal cocoon is usually
based on intraoperative and histopathology findings.11
The characteristic finding is the encasement of whole or
part of small bowel by a thick shiny membrane, aptly simu-lating
a cocoon. Small bowel loops are stuck together by
flimsy adhesions separated easily by blunt or sharp
dissection.12
Surgery is the cornerstone in the management of abdom-inal
cocoon. It includes careful dissection and excision of
thick sac around small bowel. Resection of bowel is indi-cated
only if it is non-viable.13 Some studies suggest inci-dental
appendectomy as the appendix would be difficult
to find in the future in case of acute appendicitis. Prognosis
of abdominal cocoon after surgery seems excellent and no
recurrence has been described.14
CONCLUSION
This case report describes an unusual presentation of
ovarian cyst and hydrosalpinx with abdominal cocoon
syndrome. It aims at raising awareness about this syndrome
to enable earlier preoperative diagnosis and prevent unnec-essary
bowel resection. It also mentions the role of conser-vative
nonsurgical treatment in selected cases of intestinal
obstruction with cocoon syndrome as in this case and the
need of further studies to critically analyze it.
CONFLICTS OF INTEREST
All authors have none to declare.
REFERENCES
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