Objective To summarize the computed tomography (CT) features of small intestinal obstruction caused by primary abdominal cocoon and investigate the essentials of diagnosis and differential diagnosis.Methods The retrospective descriptive study was adopted.The clinical data of 1 patient with small intestinal obstruction caused by primary abdominal cocoon who was admitted to the Second Affiliated Hospital of Jiaxing University on October 6,2014 were collected.The patient underwent abdominal CT on admission and at 10 hours after admission.The patient received emergency exploratory laparotomy after preoperative preparation,and then postoperative regular symptomatic treatment and pathological examination.Results of abdominal CT were observed,including imaging features of abdominal masses,extent of small intestinal obstruction,situation of intestinal tube within the masses,vessel distribution in the mesentery and fibrous capsules around the mesentery.Situation of operation,routine blood test,biochemical indicator,blood coagulation indexes,postoperative recovery,complications,results of pathological examination and situation of patient during follow-up were recorded.The follow-up by telephone interview and outpatient examination was applied to the patient till October 31,2015,including detecting the dietary,with or without symptoms of abdominal pain and distension,haematemesis and hematochezia,routine blood retest,liver function,renal function and CT.Results Results of abdominal CT on admission:(1) coronal plain scan of abdominal CT showed that there were signs of incomplete intestinal obstruction,and local small intestinal dilatation and gas accumulation in left abdominal region without specific sign.(2) Plain scan of abdominal CT showed that there were the "coated sign" with thickened fibrous capsules around the intestinal tube," banana shape '" with agglomerate and expanding-distortion intestinal tube and aggregative,stretching and twisting mesentery with abnormal vessel distribution.(3) Sagittal reconstruction images of abdominal CT showed that a huge mass consisted of fibrous capsules as cocoon and agglomerate and expanding-distortion intestinal tube was petal-like and fixed on posterior abdominal wall.(4) Coronal reconstruction images of abdominal CT showed that agglomerate and expanding-distortion intestinal tube was annularly surrounded by uneven thickness fibrous capsules with abnormal vessel distribution in the mesentery.Results of abdominal CT at 10 hours after admission:(1) coronal plain scan of abdominal CT showed that small intestinal obstruction was obviously exacerbated and expanding intestinal tubes were increased and aggravated.(2) Plain scan of abdominal CT showed that a typical sign of small intestinal obstruction was exacerbated and there were multiple air-fluid levels in the agglomerate and expanding-distortion intestinal tube with fluid and gas accumulation.Patient underwent successful enterodialysis + resection of fibrous capsules.During operation,a huge mass in the intestine from suspensory ligament of duodenum to ileocecum was fixed on posterior abdominal wall and surrounded by dense,smooth and white fibrous capsules,partial colon was also surrounded by fibrous capsules and greater omentum was missing.Patient received the postoperative supporting treatments of fasting,anti-infection and inhibition of acid.Number of white blood cells,absolute value and percentage of neutrophils,levels of high-sensitivity C-reactive protein and procalcitonin were 17.10 × 109/L,15.70 × 109/L,91.5％,127.49 mg/L and 1.370 μg/L by blood routine retest at postoperative day 1,respectively.Patient had normal liver,renal and coagulation functions.Fluid diet intake at postoperative week 1 was gradually replaced by normal diet intake.Patient had normal liver and renal functions by blood routine retest at postoperative day 10 and a good recovery without intestinal fistula,abdominal and pulmonary infections and other complications.Postoperative pathological examination showed that gross specimen was mainly composed of cocoon-shaped,grayish white and tough fibrous capsules.Fibrous capsules were consisted of proliferative fibrofatty tissues by microscope observation,with small vascular hyperplasia and large numbers of the inflammatory cell infiltration.Patient was diagnosed with small intestinal obstruction caused by primary abdominal cocoon after operation,and followed up for 1 year with normal diet intake and without abdominal pain and distension,nausea and vomiting,melena and discomfort.There was normal blood routine retest,liver and renal functions and distribution of the intestine in abdomen by CT examination.No dilatation of the intestinal tube was found and strip-like high density shadow in ileocecum was detected and considered as remnant fibrous capsules.Conclusion Imaging features of small intestinal obstruction caused by primary abdominal cocoon include agglomerate and expanding-distortion intestinal tube fixed on abdomen,partial intestinal tubes dilatation,intestinal fluid accumulation and air-fluid level,aggregative,stretching and twisting mesentery with abnormal vessel distribution,thickened fibrous capsules around intestinal loops and among intestinal tubes.%目的 总结原发性腹茧症致小肠梗阻腹部CT检查的影像学特征,探讨其诊断及鉴别诊断要点.方法 采用回顾性描述性研究方法.收集2014年10月6日嘉兴学院附属第二医院收治的1例原发性腹茧症致小肠梗阻患者的临床资料,患者入院时、住院10 h后行腹部CT检查.完善术前准备后急诊行剖腹探查,术后常规对症支持治疗,行病理学检查.观察腹部CT检查结果:腹部包块影像学特征、肠梗阻程度、包块内肠管情况、系膜内血管走行及其周围的纤维包膜.记录手术治疗情况、术后血常规、生化指标、凝血指标、术后恢复情况及并发症、术后病理学检查结果、随访期间患者情况.采用电话及门诊方式随访,了解患者饮食情况和有无腹痛腹胀、呕血、便血等症状;复查血常规、肝功能、肾功能、CT.随访时间截至2015年10月31日.结果 入院时腹部CT检查:(1)腹部CT检查冠状位平扫:不全性肠梗阻征象,左侧腹部局部小肠肠管扩张积气,无特异性征象.(2)腹部CT检查平扫:肠管周围见增厚纤维包膜,呈包膜征;聚集成团及扩张扭曲的小肠肠管,呈香蕉状;其小肠系膜聚集、牵拉及扭转,系膜内血管走行异常.(3)腹部CT检查矢状位重建图像:纤维包膜茧样包裹聚集成团及扩张扭曲的小肠肠管形成一巨大包块,呈花瓣状,固定于腹后壁.(4)腹部CT检查冠状位重建图像:厚薄不一的纤维包膜环状包裹聚集成团及扩张的小肠,其系膜内血管走行分布异常.住院10h后复查腹部CT:(1)腹部CT检查冠状位平扫:肠梗阻征象较前明显加重,扩张肠管较前增多,扩张程度加剧.(2)腹部CT检查平扫:典型肠梗阻征象,较前加重,聚集成团、扩张水肿、积液积气的小肠肠管内有多个液平面.患者顺利行肠粘连松解+纤维包膜切除术.术中见腹腔内有一巨大包块,固定于腹后壁,为致密、光滑、白色纤维膜包裹自十二指肠悬韧带至回盲部的全部小肠,部分结肠被纤维膜覆盖,大网膜缺如.术后患者予禁食、抗感染、抑酸等对症支持治疗.术后第1天复查血常规WBC 17.10×109/L,中性粒细胞绝对值15.70×109/L,中性粒细胞百分数91.5％,超敏C反应蛋白127.49 mg/L,降钙素原1.370 μg/L.患者肝功能、肾功能、凝血功能均正常.术后1周进食流质饮食,逐步恢复为普通饮食,术后第10天复查血常规、肝肾功能正常.患者恢复顺利,无肠瘘、腹腔内感染及肺部感染等术后并发症发生.术后病理学检查结果:大体标本为多块蚕茧状、灰白色、质地坚韧的纤维膜.镜下所见包膜为增生的纤维脂肪组织,伴小血管增生及大量炎症细胞浸润.术后诊断为原发性腹茧症,肠梗阻.术后随访1年,患者进食良好,无腹痛腹胀、恶心呕吐、黑便等不适.复查血常规、肝功能、肾功能正常;腹部CT检查示小肠腹腔内分布无异常,无肠管扩张,回盲部区见条索状高密度影,考虑残留的纤维包膜.结论 原发性腹茧症致小肠梗阻腹部CT检查的影像学主要表现为腹部包块内聚集成团及扩张的小肠肠管,固定在腹部的某一部位;部分肠管扩张、肠腔积液及液-气平面;受累及的小肠系膜聚集、牵拉及扭转,其系膜内血管走行异常;聚集肠襻周围及肠管间可见增厚纤维包膜.
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