Idiopathic Sclerosing Peritonitis – A Rare Cause of Sub-acute Intestinal Obstruction Presenting as Massive Ovarian Edema and Ascites – a Case Report

摘要

Introduction: Idiopathic encapsulating sclerosing peritonitis (or abdominal cocoon) is a rare cause of small bowel obstruction characterized by fibrotic encapsulation of the bowel. Diagnosis is usually during laparotomy.Case report: A 21-year-old female patient was admitted with symptoms of subacute intestinal obstruction. She had a history of bilateral ovariotomy for bilateral ovarian enlargement with ascites and right hydrothorax one month back, which had revealed massive edema of the ovaries with stromal hyperplasia and hyperthecosis. After a conservative management trial for few days, she underwent an exploratory laparotomy: Mildly dilated loops of small bowel were found with a thin flimsy layer of fibrous tissue over the loops with interloopal adhesions and three strictures in the region of the ileum. The serosa of the sigmoid colon was studded with multiple nodules which were soft and friable. With a suspicion of tuberculosis or malignancy, limited resection of the involved ileum with caecum and ascending colon and an end-to-end ileo-transverse anastomosis was done and multiple biopsies were taken from the surface of the nodules on the sigmoid colon. The histological diagnosis revealed sclerosing peritonitis with serositis. The patient had an uneventful recovery.Discussion: The presentation of subacute intestinal obstruction due to sclerosing peritonitis in a young female with massive ovarian masses due to ovarian edema and hyperthecosis with stromal hyperplasia makes this case a rare one. The fibrosed capsule that usually is seen in patients with abdominal cocoon was flimsy and not well-formed in this case and did not draw attention to the diagnosis even at the time of laparotomy. Clinicians must rigorously pursue a preoperative diagnosis, as it may prevent a “surprise” upon laparotomy. Introduction Idiopathic encapsulating sclerosing peritonitis (or abdominal cocoon) is a rare cause of small bowel obstruction characterized by fibrotic encapsulation of the bowel, first described and named by Foo et al. in 1978 (1). Diagnosis is usually during laparotomy. It is catagorized into primary and secondary forms (2). The idiopathic (primary) form is rare. The exact etiology of the disease remains obscure (3). Meigs’ syndrome is characterised by ovarian fibromas with ascites and usually a right-sided hydrothorax. It is termed as Pseudo-Meigs’, if the ovarian tumor is malignant.We present a rare case of a 21-year-old female patient with an ovarian tumor with ascites suggestive of Meigs’ or Pseudo-Meigs’ syndrome initially, who underwent surgery and subsequently developed features of subacute intestinal obstruction one month later, which turned out to be caused by multiple ileal strictures due to sclerosing peritonitis. The ovarian pathology was massive edema of ovary with hyperthecosis and stromal hyperplasia and had no features of malignancy. We also discuss the various clinical conditions that can be thought of in such a clinical scenario with a review of the literature. Case report A 21-year-old female patient presented with a 15-day history of dull aching lower abdominal pain with slowly progressive distension of abdomen associated with few episodes of non-bilious vomiting for 2 days. She did not give any history of irregular bowel habits, jaundice, loss of appetite or weight, or generalized swelling of limbs. She experienced shortness of breath especially on lying down. She gave a past history of having irregular menses for the past one year for which she had been taking oral contraceptive pills (estrogen+progestrone) for the past 3 months. She did not have any past history of abdominal surgeries or tuberculosis. There was no family history of any ovarian, breast or bowel cancer. Examination revealed a pale but comfortable girl. Her vital parameters were stable and the positive findings were diffuse abdominal distension with fluid thrill and horse-shoe shaped dullness suggestive of gross ascites. There was no palpable mass,