Bowel obstruction and perforation due to a large gallstone. A case report

IntroductionGallstone bowel obstruction is a rare form of mechanical ileus usually presenting in elderly patients, and is associated with chronic or acute cholecystitis episodes.Case presentationWe present the case of an 80 year old female with abdominal pain, inability to defecate and recurrent episodes of diarrhea for the past 8 months. CT examination uncovered a cholecystoduodenal fistula along with gas in the gall bladder and the presence of a ≥2 cm gallstone inside the small bowel lumen causing obstruction. Patient was admitted to the operating room, where a 3.2 cm gallstone was located in the terminal ileus. A rupture was found in the antimesenteric part of a discolored small bowel segment, approximately 60 cm from the ileocaecal valve, through which the gallstone was recovered. The bowel regained its peristalsis, and the rupture was debrided and sutured. Patient was discharged uneventfully on the 6th postoperative day.DiscussionGallstone ileus is caused due to the impaction of a gallstone inside the bowel lumen. It usually passes through a fistula connecting the gallstone with the gastrointestinal tract. It can present with nonspecific or acute abdominal symptoms. CT usually confirms the diagnosis, while there are a number of treatment options; conservative, minimal invasive and surgical. Our patient was successfully relieved of the obstruction through recovery of the gallstone using open surgery, with no repair of the fistula.ConclussionAlthough rare, gallstones must be suspected as a possible cause of bowel obstruction, especially in elderly patients reporting biliary symptoms.     

Laparoscopic management for spontaneous jejunal perforation caused by nonspecific ulcer: A case report

IntroductionNonspecific small bowel ulcers are rare and there have been limited reports. We applied laparoscopic surgery successfully for the perforation caused by this disease of jejunum.Presentation of case: A 70-year-old man visited to our hospital with complaint of abdominal pain and fever. He was diagnosed abdominal peritonitis with findings of intraperitoneal gas and fluid. Emergency laparoscopic surgery was performed. A perforation 5 mm in diameter was recognized in jejunum opposite side of mesentery. Partial resection of jejunum with end-to-end anastomosis and peritoneal lavage were performed. Pathologically, an ulcer was recognized around the blowout perforation without specific inflammation. He was discharged uneventfully 12 days after surgery.ConclusionLaparoscopic surgery has diagnostic and therapeutic advantages because of its lower invasion with a good operation view, and in case of the small bowel, it is easy to shift extra-corporeal maneuver.     

Octreotide improved the quality of life in a child with malignant bowel obstruction caused by peritoneal dissemination of colon cancer

This is a first pediatric case about the efficacy of octreotide for improving symptoms of malignant bowel obstruction. A 12-year-old boy was referred to our hospital for treatment of transverse colon cancer with peritoneal dissemination. A transverse colectomy was undertaken with postoperative adjuvant chemotherapy. Seven months later, severe abdominal symptoms occurred caused by incomplete bowel obstruction owing to tumor progression. The patient's quality of life decreased with a resultant disturbed mental condition. His parents sought to stop chemotherapy and for him to receive palliative care at home. We suggested nasogastric tube placement, but this was rejected. After obtaining informed consent, octreotide was administered intravenously. After 1 week, abdominal symptoms improved and the boy's complaints stopped. He had a good appetite and was able to eat small amounts of food. He was able to spend his final 2 months at home without nausea and in his family surroundings.     

A rare case report of patent vitellointestinal duct causing bowel obstruction in an adult

IntroductionPatent vitellointestinal duct occurs in about 2% of the population which unusually leads to small intestinal obstruction associated with high morbidity and mortality. Here we are reporting an unusual case of patent vitellointestinal duct causing small intestinal obstruction in an adult patient.Presentation of caseA 22-year-old male without any medical illness presented as an emergency with a 3 day hystory of abdominal pain, multiple episode of vomiting and abdominal distention. Distended abdomen and sign of peritonitis were found on abdominal examination. Abdominal X-rays revealed multiple small intestinal air-fluid levels. A patent vitellointestinal duct extending from distal ileum to the posterior wall of the umbilicus was found causing closed loop ileal obstruction during laparotomy. Resection of a vitellointestinal duct along with gangrenous distal ileum and cecum with ileocolostomy was performed. He was discharged on the 8 th postoperative day.DiscussionDiagnosing and management of cause of intestinal obstruction in patients without history of abdominal surgery is very challenging. Early resuscitation and timely surgical intervention of intestinal obstruction due to a rare patent vitellointestinal duct can be life-saving measure.ConclusionThe patent vitellointestinal duct is an uncommon entity in adults and moreover this disorder leading to intestinal obstruction is very rare. Surgeons should be aware of this infrequent cause of small bowel obstruction to allow for early diagnosis and to facilitate better patient outcomes.     

A case report of small bowel obstruction secondary to congenital peritoneal band in adult

IntroductionSmall bowel obstruction (SBO) is common in adult surgical procedures, mainly due to postoperative adhesions. Acute SBO in adults without history of abdominal surgery, trauma or clinical hernia is less common and has various etiologies. Congenital band is an extremely rare cause.Presentation of caseA 56-year-old man was admitted to our hospital with a two-day history of abdominal pain and bilious vomiting. He had no history of abdominal surgery or any other medical problems. A contrast-enhanced CT of the abdomen showed a distention of small bowel loops with transition point in the right hypochondrium. Distended loops of small bowel were located in the left side of the abdomen, whereas collapsed loops was located in the right side. The normal bowel wall enhancement was preserved. After initial treatment with intravenous fluid and nasogastric suction, he was operated. At laparoscopy a band obstructing the ileum was clearly observed. This anomalous band extending from gallbladder to transverse mesocolon caused a small window leading to internal herniation of the small bowel and obstruction. The band was coagulated and divided. Postoperative outcome was uneventful and the patient was discharged on the second postoperative day. There was no recurrence of symptoms on subsequent follow-up.DiscussionCongenital peritoneal bands are not frequently encountered in surgical practice and these bands are often difficult to classify and define. Diagnosis of acute intestinal obstruction due to CPB must be included in the differential diagnosis in any patient with no history of abdominal surgery, trauma, clinical hernia, inflammatory bowel disease or peritoneal tuberculosis.ConclusionDespite technological advances in radiology preoperative diagnosis remains difficult, however the diagnosis of SBO due to CPB must be considered in any patient with no history of abdominal surgery, Trauma or clinical hernia consulting for occlusive syndrome. The laparoscopic approach should be intended initially for its feasibility and benefits.     

Laparoscopic surgery for the management of obstruction of the gastric outlet and small bowel following previous laparotomy for major upper gastrointestinal resection or cancer palliation: a new concept

BACKGROUND: Surgical relief of gastric outlet obstruction (GOO) or small bowel obstruction in patients who had undergone major resection or palliative bypass surgery for malignancy is conventionally achieved at a laparotomy. The potential role of minimally invasive surgery in the management of these complications has not been previously explored. METHODS: Between 2003 and 2004, 4 consecutive patients, age range 37 to 72 years, where admitted with gastric outlet or proximal small bowel obstruction following previous open surgery for suspected intra-abdominal malignancy, under the care of one surgeon. The respective past histories of these patients were recurrent GOO and concomitant distal biliary obstruction following a previous open gastric bypass elsewhere for metastatic pancreatic head cancer; persistent adhesive small bowel obstruction following radical gastrectomy for gastric cancer; GOO secondary to intra-abdominal recurrence 6 months after hepatobiliary resection for hilar cholangiocarcinoma; and GOO following previous pancreatico-duodenectomy for suspected pancreatic head cancer. Their respective surgical management consisted of a laparoscopic re-do gastric bypass and concomitant cholecystojejunostomy; adhesiolysis and revision of the Roux-en-Y enteric anastomosis; a Devine exclusion gastroenterostomy; and resection and refashioning of the gastroenterostomy. RESULTS: There were no conversions to open surgery and no postoperative complications. The median operating time was 240 minutes (range, 145 to 300 minutes). Oral free fluid intake was resumed on postoperative day (POD) 1, while diet was resumed between POD 2 and 4. The median postoperative hospital stay was 15.5 days (range, 14 to 25 days). CONCLUSION: Previous laparotomy and major resection or palliation of malignancy do not preclude the application of the laparoscopic approach for the management of upper gastrointestinal obstruction. Laparoscopic adhesiolysis and revision of enteroenteric and gastroenteric anastomoses are feasible management options in the hands of those experienced with complex laparoscopic surgery.     

A single centre case series of gallstone sigmoid ileus management

Aims/IntroductionGallstone sigmoid ileus is a rare condition that presents with symptoms of large bowel obstruction secondary to a gallstone impacted within the sigmoid colon. This arises because of three primary factors: cholelithiasis causing a cholecystoenteric fistula; a gallstone large enough to obstruct the bowel lumen; and narrowing of the bowel.We describe 3 patients treated in a district general hospital over a 3-year period, and discuss their management.MethodsCases were retrospectively analysed from a single center between 2015 and 2017 in line with the SCARE guidelines.Results3 patients – 2 female, 1 male. Age: 89, 68, 69 years. 2 cholecystocolonic fistulae, 1 cholecystoenteric (small bowel) fistula.Patient 1: Unsuccessful endoscopic attempts to retrieve the (5 × 5 cm) gallstone resulted in surgery. Retrograde milking of the stone to caecum enabled removal via modified appendicectomy.Patient 2: Endoscopy and lithotripsy failed to fragment stone. Prior to laparotomy the stone was palpated in the proximal rectum enabling manual extraction.Patient 3: Laparotomy for gallstone ileus failed to identify a stone within the small bowel. Gallstone sigmoid ileus then developed. Conservative measures successfully decompressed the large bowel 6 days post-operation.ConclusionsThis is the first case series highlighting the differing strategies and challenges faced by clinicians managing gallstone sigmoid ileus. Conservative measures (including manual evacuation), endoscopy, lithotripsy and surgery all play important roles in relieving large bowel obstruction. It is essential to tailor care to individual patients’ needs given the complexities of this potentially life threatening condition.     

Symptom Control in Patients With Locally Recurrent Rectal Cancer

Background: Although resection of locally recurrent rectal cancer has been associated with improved survival, clinical outcomes after such repeat surgery have been incompletely characterized.Methods: From 1997 to 1999, 105 consecutive patients requiring repeat surgery for locally recurrent rectal cancer were identified. Patients were observed for a minimum of 2 years or until death.Results: An operation was performed with palliative intent in 23% of patients. Before repeat surgery, 79% of the palliative-intent patients had symptoms: 21% bleeding, 42% obstruction, and 21% pain. After repeat surgery with palliative intent, improvement was noted in 40% with bleeding, 70% with obstruction, and 20% with pain. Additional or recurrent symptoms were noted in 87% during follow-up. Seventy-seven percent of patients had an operation with nonpalliative intent. Before repeat surgery, 57% of nonpalliative patients had symptoms, with 32% experiencing bleeding, 11% obstruction, and 19% pain. After repeat surgery with nonpalliative intent, initial improvement was noted in 88% with bleeding, 78% with obstruction, and 40% with pain. During follow-up, symptoms arose in 37% of the initially asymptomatic patients, and additional or recurrent symptoms were seen in 63% of those previously symptomatic.Conclusions: Although symptomatic relief is associated with repeat surgery, the recurrence or development of alternate symptoms makes a completely asymptomatic clinical course uncommon.     

A case report of desmoid tumour—a forgotten aspect of FAP?

IntroductionDesmoid tumours are locally aggressive tumours which are common in Familial Adenomatous Polyposis (FAP).Presentation of caseA 20-year old Familial Adenomatous Polyposis (FAP) patient presented with abdominal pain and distention. Abdominal imaging showed small bowel obstruction and hydronephrosis due to a pelvic mass. This mass showed significant enlargement on repeat imaging, and a diagnostic biopsy confirmed desmoid tumour.The mass was deemed unresectable and he was initially started on sulindac and raloxifene. Repeat imaging however showed further enlargement of the tumour, and therefore vinblastine + methotrexate chemotherapy was commenced, with a good response.DiscussionFAP is an autosomal dominant condition caused by a germline mutation in the adenomatous polyposis coli (APC) gene. Gardner’s syndrome is also caused by a mutation in the APC gene, and is now considered a different phenotypic presentation of FAP. Desmoid tumours are initially kept under observation while their size remains stable. Treatment options for enlarging desmoids tumours include surgery (first-line), radiotherapy, and systemic therapy with non-cytotoxic and cytotoxic therapy.ConclusionFAP patients should be examined regularly post-panprocotocolectomy, since desmoid tumours may arise. The presence of epidermal cysts in this FAP patient suggests a diagnosis of Gardner’s syndrome.     

Acute diffuse peritonitis due to spontaneous rupture of a primary gastrointestinal stromal tumor of the jejunum: A case report

IntroductionGastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Overt peritonitis caused by GIST rupture is very uncommon. Three types of GIST rupture have been described: closed perforation due to abscess (abscess type), hemoperitoneum leading to rupture of the hematoma capsule in the tumor (hemoperitoneum type), and perforation of the digestive tract via a fistula leading to central necrosis of the tumor (bowel perforation type). This report describes a patient with spontaneous tumor rupture and diffuse peritonitis, a variant of the bowel perforation type of GIST rupture.Presentation of caseA 74-year-old man presented with symptoms of vomiting and abdominal pain. Computed tomography (CT) scan revealed an approximately 10 × 7-cm mass in the pelvis with free air and fluid collection. Emergency laparotomy revealed a tumor in the jejunum, which was ruptured with a hole measuring 5 mm in diameter. The tumor and part of the jejunum were resected. Immunohistochemically, the mass was diagnosed as a GIST originating from the gastrointestinal tract. Despite chemotherapy with imatinib mesylate, the patient died 22 months after surgery.ConclusionsThis report describes a patient with acute diffuse peritonitis due to spontaneous rupture of a primary GIST of the jejunum.     

Small,spontaneously ruptured gastrointestinal stromal tumor in the small intestine causing hemoperitoneum: A case report

IntroductionGastrointestinal stromal tumors (GISTs) are clinically asymptomatic until they reach a significant size; therefore, GISTs that are 2 cm or less are typically asymptomatic. Patients with symptomatic GISTs typically present with abdominal pain, gastrointestinal bleeding, or a palpable mass but rarely present with hemoperitoneum.Presentation of caseA 72-year-old Japanese man presented to us with acute onset abdominal pain. Physical examination showed peritoneal irritation in the lower abdomen. Findings of abdominal computed tomography were suggestive of hemoperitoneum; therefore, urgent surgery was performed. Approximately 1500 ml of blood in the abdominal cavity was removed. A small, ruptured mass was found in the middle of the small intestine, and partial resection of the small intestine, including the mass, was performed. The resected tumor was 2 cm in size and exhibited an exophytic growth pattern. Immunohistochemical staining revealed that the tumor was positive for KIT and CD34; therefore, a final diagnosis of GIST was made. Treatment with imatinib at 400 mg per day was started from postoperative month 1. The patient is doing well without recurrence 5 months after surgery.DiscussionEven small GISTs in the small intestine can spontaneously rupture and cause hemoperitoneum. Moreover, when a patient presents with sudden abdominal pain and hemoperitoneum without an evident mass on imaging, clinicians should be aware of the possibility of bleeding from a small GIST in the small intestine.ConclusionWe present an extremely rare case of a patient with a small, spontaneously ruptured GIST in the small intestine, resulting in hemoperitoneum.     

Possible relation between partial small bowel obstruction and severe postprandial reactive hypoglycemia after Roux-en-Y gastric bypass

BackgroundAlthough dietary treatment ameliorates symptoms in most patients with postbariatric hypoglycemia (PBH), there is a subgroup with severe symptoms that do not respond sufficiently to either diet or drugs. A clinical observation showed that those patients additionally experienced postprandial abdominal discomfort or pain.ObjectivesThis report describes patients with severe PBH following laparoscopic Roux-en Y gastric bypass undergoing corrective surgery to alleviate partial small bowel obstruction (kink, adhesions, dysfunctional anastomosis) and the subsequent outcome regarding symptoms of PBH.SettingSahlgrenska University Hospital, Sweden.MethodsRetrospective analysis regarding hypoglycemic symptoms from medical records and a complementary telephone interview.ResultsOut of 80 patients treated for severe PBH at our tertiary academic surgical unit over the last 4 years, 38 underwent corrective surgery (adhesiolysis and/or a reconstructed jejuno-jejunostomy). Out of 21 patients using medications to control hypoglycemia before corrective surgery, 19 (90.5%) discontinued the medication, and 5 of 19 (26%) no longer needed to use a blood glucometer or a continuous glucose monitor. Although patients after surgical correction still could experience PBH, symptoms were less frequent and less severe. Postprandial abdominal symptoms decreased, and patients reported improved eating quality. Patient interviews revealed that 8% became entirely free of PBH symptoms after surgery and 71% experienced significant relief.ConclusionsWe propose a possible association between severe hypoglycemic symptoms after laparoscopic Roux-en Y gastric bypass and partial small bowel obstruction. Patients with PBH not responding adequately to diet and drug treatment may benefit from assessment and intervention for partial small bowel obstruction.     

Abdominal Cocoon as a Rare Cause of Small Bowel Obstruction in an Elderly Man: Report of a Case and Review of the Literature

Abdominal cocoon is a rare cause of intestinal obstruction usually diagnosed incidentally at laparotomy. The cause and pathogenesis of the condition have not been elucidated. It primarily affects adolescent girls living in tropical and subtropical regions. Several earlier cases have been reported in males. We describe an 82-year-old man presenting with small bowel obstruction without history of previous abdominal surgery. He was treated by warfarin following aortic valve replacement. Abdominal cocoon was detected at laparotomy. Excision of membrane and lysis of adhesions led to relief of obstruction. Abdominal cocoon is a rare pathology that may be found in all kinds of populations. It may be a rare form of small bowel obstruction diagnosed during surgery in elderly patients.     

Abdominal cocoon—A rare cause of intestinal obstruction

INTRODUCTIONAbdominal cocoon syndrome is characterized by small bowel encapsulation by a fibro-collagenous membrane or “cocoon”. It is a rare cause of intestinal obstruction.PRESENTATION OF CASEA 42-year old man presented with sub-acute intestinal obstruction. Intra-operatively, the entire small bowel was found to be encapsulated in a dense fibrous sac. The peritoneal sac was excised, followed by lysis of the inter-loop adhesions. Postoperative recovery was unremarkable.DISCUSSIONMost patients with abdominal cocoon syndrome present with features of recurrent acute or chronic small bowel obstruction secondary to kinking and/or compression of the intestines within the constricting cocoon. An abdominal mass may also be present due to an encapsulated cluster of dilated small bowel loops.CONCLUSIONAbdominal cocoon is a rare condition causing intestinal obstruction and diagnosis requires a high index of suspicion because of the nonspecific clinical picture. CECT of the abdomen is a useful radiological tool to aid in preoperative diagnosis. Peritoneal sac excision and adhesiolysis is the treatment and the outcome is usually satisfactory.     

The role of laparoscopic adhesiolysis in the treatment of patients with chronic abdominal pain or recurrent bowel obstruction.

BACKGROUND: Major abdominal operations result in random and unpredictable scar tissue formation. Intraabdominal scar tissue may contribute to recurrent episodes of bowel obstruction, chronic abdominal pain, or both. Laparoscopic adhesiolysis may provide relief of symptoms in patients with prior abdominal surgery with chronic abdominal pain or recurrent bowel obstruction. METHODS: Between September 1996 and April 1999, 35 patients underwent laparoscopic adhesiolysis. Fifteen of the patients had adhesiolysis in conjunction with other major laparoscopic procedures and were excluded from the study. Twenty of the patients who underwent adhesiolysis only were retrospectively assessed for symptomatic relief as well as peri-operative morbidity and mortality. RESULTS: Two of 20 patients were not available for long-term follow-up. In the 18 remaining patients, laparoscopic adhesiolysis was performed on 13 patients with abdominal pain and 5 patients with recurrent bowel obstruction. The follow-up period ranged from 1 to 32 (mean 11) months. Sixteen of the 18 (88.9%) operations were completed laparoscopically. Two operations were converted to open for partial enterectomy. An additional enterotomy was repaired laparoscopically. All 3 operative complications were encountered in patients operated on during hospitalization for active bowel obstruction. No mortalities or blood transfusions occurred. One patient required rehospitalization for nonoperative management of an intraabdominal hematoma. Fourteen of the 18 (77.8%) had subjective improvement in their quality of life after operation. Only 1 patient has required repeat adhesiolysis. CONCLUSIONS: Laparoscopic adhesiolysis is a safe and effective management option for patients with prior abdominal surgery with chronic abdominal pain or recurrent bowel obstruction not attributed to other intraabdominal pathology. Laparoscopic intervention in patients with active bowel obstruction may increase the risk of operative complications.     

Post traumatic acquired multiple mesenteric defects

INTRODUCTIONInternal intestinal hernia has been defined as a bulging of the intestines through a normal or an abnormal peritoneal or mesenteric opening.¹ Internal hernias are a rare cause of small-bowel obstruction, with a reported incidence of 0.2–0.9%.²PRESENTATION OF CASEIn this report, the patient presented with multiple episodes of intestinal obstruction. High index of suspicion aided the appropriate management of this case. An abdominal CT revealed signs of small bowel obstruction. With negative signs and symptoms indicating adhesions, malignancy or inflammatory causes, mesenteric defect was suspected. When the patient underwent laparotomy, multiple mesenteric defects were found.DISCUSSIONIn the adult population, acquired mesenteric defects are more common than congenital defects. They can be caused by bowel surgery or abdominal trauma.¹¹ Patients with a history of blunt abdominal trauma may present with late complication caused by a missed diagnosis of an associated injury, such as bowel mesenteric injuries.In this case, the author describes a patient who developed multiple attacks of small bowel obstruction. He had no previous history of similar symptoms but did give a history of recent abdominal trauma managed conservatively. An abdominal CT was performed, and it showed signs of a mesenteric defect. In such a case, early operative intervention is essential to decrease morbidity and increase survival. ¹⁶CONCLUSIONThe diagnosis of post traumatic mesenteric injuries can be missed in conservatively managed trauma cases. For this reason, the decision of non-operative approach should be made following the exclusion of associated injuries.     

A multidisciplinary approach to desmoid tumors. When intra-abdominal fibromatosis degenerates into an abscess,which is the right treatment?

INTRODUCTIONDesmoid tumors are rare benign tumors that originates in the fibrous sheath or musculo-aponeurotic structure. Histologically benign, they tends to invade locally and to be recurrent.PRESENTATION OF CASEWe report a rare case of an intra-abdominal desmoid tumor in a patient affected by familial adenomatous polyposis, which degenerated into abscess. Male, 38 years, was hospitalized for abdominal pain, bowel obstruction and fever. The computed tomography showed a big dishomogeneous mass occupying the whole mesentery with internal massive liquefaction. The mass extended from the epigastrium for 13 cm up to L3. On the right mesogastric side a solid, thick mass of about 2 cm, with a length of 4.5 cm, was identified; it was not cleavable from the wall and from some of the loops. We decided to perform a computed tomography-guided percutaneous drainage. Two hundred ml of purulent necrotic material was aspirated, and washing with antibiotic solution was carried out. Cytological examination of fluid drainage showed histiocytes and neutrophils. At follow-up, the patient's clinical condition had improved. An abdominal ultrasound showed a substantial reduction in the diameter of the mass.DISCUSSIONDiagnosis and treatment of desmoids tumor in patients with familial adenomatous polyposis may be difficult, especially when desmoids are located intra-abdominally and in the mesentery. Seldom will desmoid tumors be complicated by abscess formation.CONCLUSIONThe management of desmoids tumors is not easy and the choice of the best treatment may be difficult due to the different possible anatomical presentations.     

Two giant peritoneal loose bodies were simultaneously found in one patient: A case report and review of the literature

IntroductionPeritoneal loose body(PLB) is usually small, therefore giant Peritoneal loose body(gPLB) with a diameter >5 cm has rarely been described in the literatures. We report a case of two gPLB simultaneously found in one patient.Presentation of caseA healthy 79-year-old man palpated himself a solid mass with alternating localizations in his peritoneal cavity 6 months ago. It was not the complaint of frequency of urinatior until he saw the doctor a week ago. Surprisingly, two oval-shaped masses were simultaneously discovered by computed tomography (CT). One was in the peritoneal cavity, measuring 10.4*8.3 cm, weight 182.5 g, another was in the pelvic cavity, measuring 7.6*6.0 cm, weight 98.4 g. The case was confirmed by surgical operation.DiscussionThe gPLB is considered as uncommon. Two gPLB which were simultaneously discovered in one patient have never been reported in the literatures. The small PLB is usually asmptomatic, occasionally, the gPLB can cause symptoms with acute retention of urine or intestinal obstruction. It is crucial to diagnosis the peritoneal loose body.ConclusionTwo gPLB that situated in one patient are rare findings. Clinically, if a solid mass alternating localizations cound be palpated in the Peritoneal cavity, CT or other imaging shows an oval-shaped mass with calcifications in the central region, PLB should be considered. Surgical removal is recommended for the patient with acute retention of urine or intestinal obstruction or unclear diagnosis.     

A rare cause of small bowel obstruction: Abdominal cocoon

INTRODUCTIONThe clinical manifestations of abdominal ‘cocoon’ are non-specific and hence its diagnosis is rarely made preoperatively and the management is often delayed. Surgery remains the main stay of treatment with satisfactory outcome and comprises excision of the fibrous membrane, meticulous adhesionolysis and release of the entrapped small bowel.PRESENTATION OF CASEA 45-year-old male patient presented with 6-month history of progressive subacute small bowel obstruction. After initial radiological investigations, he underwent diagnostic laparoscopy and was misdiagnosed as abdominal tuberculosis. He was started on anti-tuberculous therapy, but exploratory laparotomy was carried out after failure to respond to anti-tuberculous therapy. At laparotomy, the abdominal ‘cocoon’ which was encapsulating the entire small bowel was excised, and the adhesions were carefully lysed. The patient remained well and without recurrence at 1-year follow-up.DISCUSSIONAbdominal ‘cocoon’ is a rare cause of subacute, acute and chronic small bowel obstruction. Its diagnosis is rarely made preoperatively.CONCLUSIONAbdominal ‘cocoon’ should be thought of as a rare cause of small bowel obstruction. It may be mistaken with abdominal tuberculosis. Surgery remains the mainstay of curative treatment.