Hospital: Hospital Universitario Puerta de Hierro.
Nº: C2019-75
Aut@r o Autores: M. Alfageme Zubillaga, P. García Benedito, C. Cortés León, R.M. Ruiz Peralbo, P.M. Hernandez Guilabert, M.L. Collado Torres.
Presentación
A 73 year old man was admitted to our surgical department with generalited abdominal pain, distension, nausea and vomiting. Seven months ago he started to complain of abdominal fullness, decreased oral intake, weigth loss and weakness. Laboratory findings were not specific. CT scan showed small bowel dilated, ascitis and hepatomegaly.An endoscopy was performed showing slight swellingin jejunal loops. In the histology the findings were suggestive of eosinophilic gastroenteritis.Due to the poor clinical evolution it was decided to perform exploratory laparotomy. At exploration, encapsulation of the proximal small bowel was found. A very careful meticulous adhesiolysis was done. At the same time a liver biopsy was taken. Peritoneal histologic findings showed mesothelial cell layer were denuded with fibroblast proliferation and fibrocollagenous with fibrin deposition and inflammatory mononuclear cell infiltrate. Liver biopsy showed changes associated with parenteral nutrition. The patient received treatment with corticosteroids, showing good clinical evolution.
Discusión
Encapsulating peritoneal sclerosis (EPS), is a serius and rare disorder that results in cocooning of bowel within a thickened fibrocollagenus peritoneal membrane. EPS is most commonly associated with long-term peritoneal dialysis, though medications, peritoneal infeccion and systemic inflamatory disorders have been implicated. Many cases remain idiophatic. In our patient is probably secondary to eosinophilic gastroenteritis.Patients with EPS often present with vague abdominal symptoms, often recurrent episodes of bowell obstruction (1).The findings on radiographs are usually normal. CT is the mainstay for diagnosis of EPS. Routine portal venous phase CT is usually sufficient to give adequate information (2). - The peritoneum is thickened, with marked continuous enhancement. - The small-bowel loops appear congregated toward the center of the abdominal cavity and are encased by a mantle that demonstrates soft-tissue attenuation. A serpentine arrengement of dilated small-bowel loops in a fixed U-shaped configuration is characteristic. - Bowel thickening may or may not be demonstrated. - There may be calcification, usually on the visceral surface of the bowel, although calcification of the parietal peritoneum has also been described. - In addition, CT can potentially help identify the cause of EPS, as well as the complications. However, EPS is usually diagnosed intraoperatively. Treatment for EPS involves treating the underlying condition or eliminating possible inciting agents and nutritional support, EPS specific treatment depends on the disease stage. In the inflammatory stage, corticosteroids are the treatment of choice, while in the fibrotic stage, tamoxifen may bebeneficial. Surgical intervention, consisting of peritonectomy and enterolysis.
Conclusión
EPS is a rare disorder. CT is the imaging modality of choice. It allows to obtain a diagnosis of suspicion, detect complications and sometimes find the cause of ESP.
Bibliografía
- Danford CJ, Lin SC, Smith MP, Wolf JL. Encapsulating peritoneal sclerosis. World J Gastroenterol. 2018,24(28):3101-11. - Singhal M, Krishna S, Lal A, Narayanasamy S, Bal A, Yadav TD, et al. Encapsulating Peritoneal Sclerosis: The Abdominal Cocoon. Radio