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Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 61-63

Unusual presentation of diffusely infiltrative gastric carcinoma as abdominal cocoon in a young patient

Department of Radiodiagnosis, Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, Haryana, India

Date of Web Publication1-Mar-2018

Correspondence Address:
Dr. Puneet Mittal
F-9, Residential Complex, Mm University, Mullana, Ambala - 133 207, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijhas.IJHAS_135_16

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Abdominal cocoon formation is a chronic condition which usually presents with intermittent bowel obstruction and is typically described with benign conditions. In developing countries like India, where tuberculosis is endemic, abdominal cocoon in young patients without any other known chronic disease is mostly associated with abdominal tuberculosis. Abdominal cocoon secondary to malignant causes has been reported but is extremely rare, mostly in association with ovarian thecomas. Abdominal cocoon secondary to abdominal tuberculosis has been described only in few reports. We present a case of young female who presented with abdominal cocoon which was subsequently proven to be secondary to diffusely infiltrative gastric carcinoma.

Keywords: Adenocarcinoma, cocoon, gastric, multidetector computed tomography, obstruction

How to cite this article:
Gupta R, Gupta S, Mittal P, Mittal A. Unusual presentation of diffusely infiltrative gastric carcinoma as abdominal cocoon in a young patient. Int J Health Allied Sci 2018;7:61-3

How to cite this URL:
Gupta R, Gupta S, Mittal P, Mittal A. Unusual presentation of diffusely infiltrative gastric carcinoma as abdominal cocoon in a young patient. Int J Health Allied Sci [serial online] 2018 [cited 2023 Feb 4];7:61-3. Available from: https://www.ijhas.in/text.asp?2018/7/1/61/226255

  Introduction Top

Abdominal cocoon also referred to as sclerosing encapsulating peritonitis is a chronic condition which is characterized by encapsulation of small bowel loops by thickening encapsulating membrane which is usually fibrocollagenous in nature.[1] It has been reported as an idiopathic condition in young females or as secondary to a variety of conditions such as chronic dialysis, drugs, ventriculoperitoneal shunts, and postliver transplantation and much more common in developing countries secondary to tuberculosis. Malignancy is an extremely rare cause of abdominal cocoon formation.[1],[2] In the present case report, we describe a case of malignant cocoon secondary to gastric adenocarcinoma. This case highlights that malignant causes, although rare, should also be considered in such cases.

  Case Report Top

A 22-year-old female patient presented with abdominal distension, low-grade fever, and history of intermittent small bowel obstruction. On examination, nontender abdominal lump was seen centered in the right paraumbilical region. Contrast-enhanced multidetector computed tomography (CT) scan of the abdomen was obtained which showed diffuse thickening of the distal body and antrum of the stomach measuring up to 1 cm. There was diffusely encapsulation of small bowel loops on thickened and enhancing encapsulating membrane with thickening and enhancement of visceral and parietal peritoneum giving appearance of abdominal cocoon formation [Figure 1]. Multiple subcentimeter mesenteric lymph nodes were also seen. In view of young age of patient, two differential diagnoses were considered: gastric and abdominal tuberculosis with cocoon formation and gastric malignancy with peritoneal carcinomatosis. The patient underwent upper gastrointestinal endoscopy with biopsy which showed diffusely infiltrative gastric carcinoma with signet ring cells [Figure 2]. Subsequently, the patient underwent exploratory laparotomy which showed encapsulated of small bowel loops with thick membrane from which biopsy was obtained which showed metastatic deposits. In view of advanced disease, the patient was referred for palliative chemotherapy.
Figure 1: Axial contrast-enhanced computed tomography image (a) showing diffuse mural thickening of the distal body and antrum of the stomach (white arrow). Axial (b), coronal (c), and sagittal (d) contrast-enhanced computed tomography images showing encapsulation of small bowel loops by enhancing membrane with thickening and enhancement of visceral and parietal pleural (white arrows)

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Figure 2: (a) Gastric biopsy images (H and E, ×400), (b) images showing infiltrative gastric carcinoma with signet ring cells (PAS-AB, ×400)

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  Discussion Top

Sclerosing encapsulating peritonitis or abdominal cocoon was first described by Owtschinnikow in 1907 which called in peritonitis chronica fibrosa incapsulata.[3] It has been described to have three types: in Type I, there is partial encasement of the small bowel. In Type II, the whole of small bowel is encased by the membrane. In Type III, there is also encasement of adjacent structures, such as cecum, ascending and descending colon, appendix, and ovaries.[2],[4]

In developing countries like India, tuberculosis is one of the most common causes of abdominal cocoon formation. The first case of malignancy associated with cocoon formation was described in 1976 which was secondary to gastric carcinoma.[5] Cocoon formation has been described in association with ovarian thecomas and more rarely carcinoma.[6],[7] In 2010, Pamo Reyna et al. described a series of three cases of malignant abdominal cocoon secondary to gastric adenocarcinoma (two cases) and ovarian thecoma (one case).[8] Recently, cocoon formation was also described in late advanced stage midgut neuroendocrine tumors.[9]

Exact etiopathogenesis of abdominal cocoon formation is still uncertain, but it is considered to be secondary to chronic peritoneal irritation which induces fibrotic response.[1] This explains its association with chronic inflammatory/infective processes. Similar etiopathogenesis can explain its association with mucin-producing neoplasms and other neoplasms which induce fibrotic response.[9] Diffusely infiltrative signet ring cell gastric carcinoma is a highly malignant tumor which produces dense desmoplastic response.[10] Therefore, in case of diffuse peritoneal metastasis, appearance of cocoon formation can be explained as is seen in our case. Major differential diagnoses for this condition include internal hernias and congenital peritoneal encapsulation.[11]

Imaging appearance of cocoon is well described in literature.[12] On radiography, there may be appearance of dilated bowel loops with or without air-fluid levels depending up to the extent of obstruction. On barium studies, characteristic serpentine “U-” shaped clustering of bowel loops has been described which are fixed in configuration with delayed transit. Ultrasound and CT scan reveal similar fixed clustered configuration of bowel loops with encasing membrane. Associated changes of mesenteric and omental thickening and lymphadenopathy may be seen. CT is best suited for depicting extend of bowel encasement which can help in guiding surgical management.[12]

Gastric tuberculosis is a rare condition and is usually secondary to pulmonary or other extrapulmonary site of tuberculosis. Moreover, peritoneal spread of tuberculosis can easily mimic gastric peritoneal carcinomatosis. Differentiation of gastric tuberculosis from carcinoma can be challenging on imaging as both can present with mural thickening and perigastric lymphadenopathy. A high index of suspicion is required, and biopsy is mostly required to reach the correct diagnosis.[13] Apart from tuberculosis and mucinous gastric carcinoma, other differentials include ovarian thecomas and carcinomas and midgut neuroendocrine tumors. Imaging appearances are often overlapping in these conditions and biopsy is required to reach final diagnosis.

Treatment of typical benign abdominal cocoon is mainly surgical with excision of encapsulating membrane often providing sustained relief of symptoms. Conservative treatment may be used in those with mild symptoms. Treatment of abdominal cocoon associated with malignancy is more difficult because surgical excision of encasing membrane is difficult and complication rate is high. Medical treatment to inhibit fibrotic response has been suggested in such cases.[9]

  Conclusion Top

Abdominal cocoon, even in young patients, is not always benign and may be associated with gastrointestinal malignancy. All cases of abdominal cocoon should be scrutinized for any significant bowel thickening, especially of the stomach, and biopsy should be obtained in all such cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

George V, Tammisetti VS, Surabhi VR, Shanbhogue AK. Chronic fibrosing conditions in abdominal imaging. Radiographics 2013;33:1053-80.  Back to cited text no. 1
Philips CA, Kalal CR, Kumar KN, Sharma CB, Sarin SK. Sclerosing encapsulating peritonitis in a young male secondary to adenocarcinoma of the gastrointestinal tract. SEAJCRR 2014;3:802-10.  Back to cited text no. 2
Owtschinnikow PJ. Peritonitis chronica fibrosa incapsulata. Arch Klin Chir 1907;83:623-34.  Back to cited text no. 3
Rehman ZU. Cocoon abdomen – A rare cause of intestinal obstruction. Int J Surg Case Rep 2015;11:95-7.  Back to cited text no. 4
Vorhauer W, Briere J, Passa P, Charleux H, Chelloul N. Encapsulating peritonitis symptomatic of gastric adenocarcinoma. Sem Hop 1976;52:1715-8.  Back to cited text no. 5
Clement PB, Young RH, Hanna W, Scully RE. Sclerosing peritonitis associated with luteinized thecomas of the ovary. A clinicopathological analysis of six cases. Am J Surg Pathol 1994;18:1-3.  Back to cited text no. 6
Isacson R, Segal A, Alberton J, Reinus C, Schwarz A, Grenader T, et al. Abdominal cocoon: A potential pitfall in patients with ovarian carcinoma. Tumori 2012;98:176e-8e.  Back to cited text no. 7
Pamo Reyna OG, Loza Oropeza D, Sáenz Rodríguez M, Chian García C, Verona Rubio R, Freundt Serpa N, et al. Sclerosing peritonitis: Presentation of three cases. Rev Gastroenterol Peru 2010;30:65-72.  Back to cited text no. 8
Wang YZ, King H, Diebold A. Cocoon formation in patients with midgut neuroendocrine tumors: A rare and unrecognized final pathway. Pancreas 2013;42:944-8.  Back to cited text no. 9
Hu B, El Hajj N, Sittler S, Lammert N, Barnes R, Meloni-Ehrig A, et al. Gastric cancer: Classification, histology and application of molecular pathology. J Gastrointest Oncol 2012;3:251-61.  Back to cited text no. 10
Akbulut S. Accurate definition and management of idiopathic sclerosing encapsulating peritonitis. World J Gastroenterol 2015;21:675-87.  Back to cited text no. 11
Rastogi R. Abdominal cocoon – A rare complication of abdominal tuberculosis. J Gastrointest Dig Syst 2015;5:4.  Back to cited text no. 12
Kim SE, Shim KN, Yoon SJ, Jung SA, Kim TH, Yoo K, et al. A case of gastric tuberculosis mimicking advanced gastric cancer. Korean J Intern Med 2006;21:62-7.  Back to cited text no. 13


  [Figure 1], [Figure 2]


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