Tuberculous Abdominal Cocoon With Internal Hernia - A Case Report And Review Of Literature

摘要

A 14-year-old girl was presented with features suggestive of intestinal obstruction. Past history revealed diagnosis of abdominal tuberculosis and default of anti-tuberculous therapy. Clinically, a globular mass was felt in epigastrium and umbilical region and free fluid was appreciated in the abdomen. An erect X-ray of the abdomen showed multiple air-fluid levels in the upper half of the abdomen. CECT of the abdomen revealed abnormally positioned crowded small-bowel loops with mild dilatation and multiple air-fluid levels. A provisional diagnosis of intestinal obstruction was made and the patient was taken up for explorative laparotomy which showed a well-formed thick capsule encasing the whole small bowel, the stomach and the large intestine except descending and sigmoid colon. On opening the capsule and releasing the bowel there were features suggestive of internal hernia with displaced superior mesenteric vessels. The histopathology of the capsule wall showed chronic non-specific inflammatory reaction and mature fibrous tissue. A diagnosis of abdominal cocoon with internal hernia secondary to abdominal tuberculosis was made. Introduction Abdominal cocoon presenting with intestinal obstruction is a rare finding with most cases of abdominal cocoon being primary or idiopathic. Cases of abdominal cocoon secondary to tuberculosis have been reported in literature and are on the rise in countries like India with increasing cases of tuberculosis. Internal hernia within the secondary abdominal cocoon is a rare finding and has not been reported in literature. Case Report A 14-year-old girl was admitted to the emergency department with history of abdominal pain and distension since 10 days. Past history revealed similar episodes twice in the last year which resolved spontaneously. Past records showed workup for abdominal tuberculosis with a serum adenosine deaminase level of 49.1 U/L and ascitic fluid analysis of the exudative type with 95% lymphocytes. The patient had been started on anti-tuberculosis treatment with steroids based on the findings. The patient had defaulted on the treatment after taking it for 2 months.Clinical examination of the patient revealed an anxious look and mild dehydration. Pulse was 110/minute, temperature 37.8°C, blood pressure 110/70 mmHg. There was no cyanosis or jaundice. No abnormalities of the chest or cardiovascular system were found. Local examination of the abdomen revealed a distended abdomen, hypoactive bowel sounds, and mild tenderness with free fluid in the abdomen. A tender lump was palpated in the umbilical region with mild guarding. There was no hepatomegaly or splenomegaly and rectal examination was unremarkable. Routine laboratory workup revealed a total leukocyte count of 9300 cells/ml, hemoglobin of 10.9 g %, and normal serum chemistry and normal urine analysis. PA X- ray of the chest was normal but plain standing X-ray of the abdomen showed multiple air-fluid levels with no free air under the diaphragm. Contrast enhanced CT revealed abnormally positioned, concentric, clumped, dilated bowel loops in the upper abdomen, two below the level of the superior mesenteric artery and one left of the duodenojejunal junction. A thin capsule encasing the small and large bowel was seen. Moderate ascites was noted in lower abdomen and pelvis (figure 1-4).Under a provisional clinical diagnosis of mechanical small-bowel obstruction, emergency laparotomy was performed through a midline incision. After opening the peritoneum, there was an encapsulated mass in the upper abdomen with brownish fluid occupying the lower abdomen and pelvis. The whole small bowel and part of the large bowel was covered by a dense whitish and approximately 4mm thick membrane which gave the appearance of a cocoon (figure 5). At regions the capsule was densely adherent to the anterior abdominal wall. The membrane enveloping the small bowel was incised carefully and separated from the intestinal serosa by sharp and blunt dissectio