Abdominal cocoon syndrome (idiopathic sclerosing encapsulating peritonitis): An extremely rare cause of small bowel obstruction-Two case reports and a review of literature.

Introduction: Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction in which the bowel and internal abdominal organs are wrapped with a fibrocollagenous cocoon-like encapsulating membrane [1,2]. SEP is divided into two entities: abdominal cocoons (AC), also known as idiopathic or primary sclerosing encapsulating peritonitis, which is of extremely rare type, and secondary sclerosing encapsulating peritonitis, which is the more common type. Case presentation: Two male patients from India, a 26 year old and a 36 year old, presented to our hospital complaining about abdominal pain associated with nausea and vomiting without any history of previous surgical interventions; the patients' vitals were stable. Preoperative diagnosis of abdominal cocoon was established by abdominal computed tomography. It showed multiple dilated fluid-filled small bowel loops in the center of the abdominal cavity with thin soft tissue, non-enhancing capsules encasing the small bowel loops with mesenteric congestion involving small and large bowel loops. Both patients underwent complete surgical excision of the sac without intraoperative complications. Patients had a smooth postoperative hospital course and were discharged home in good conditions. Conclusion: Patients with abdominal cocoons have a non-specific clinical presentation of intestinal obstruction. A high index of clinical suspicion in combination with the appropriate radiological investigation will increase the chance of preoperative detection of the abdominal cocoon. In patients with complete bowel obstruction, complete excision of the peritoneal sac is the standard of care.

Low grade appendiceal mucinous neoplasm mimicking an ovarian cyst: A case report.

INTRODUCTION: Appendiceal mucocele (AM) is a very rare neoplasm with an incidence of 0.2-0.3% of all appendectomy specimens. AM usually defined as an intraluminal dilation of the appendix in response to mucin accumulation. The preoperative diagnosis is difficult and can be misdiagnosed to any of the other differential diagnosis especially in female patients. If it is suspected, imaging modalities and colonoscopy can be helpful as a guide for the right surgical approach. PRESENTATION OF CASE: A 41-year-old lady who found to have an appendicular tumor discovered incidentally on magnetic resonance imaging (MRI) of the abdomen during a follow-up in the referral hospital for persistent right lower quadrant abdominal pain with enlarging right ovarian cyst for 2 years. MRI revealed a sizeable cyst measuring 7 × 4 × 3 cm in the right iliac fossa (RIF) region with high suspicion of an AM. The patient was managed with open right limited hemicolectomy. The patient was diagnosed as a well-differentiated low-grade AM neoplasm with stage 0 (pTis, pN0, M0) based on the 8th edition of the American Joint Committee on Cancer (AJCC) Staging System. The patient had an uneventful recovery and advised for regular follow-up of at least 5 years. DISCUSSION: AM is a very rare neoplasm. The imaging modalities that can be diagnostic methods are the abdominal ultrasonography (US), transvaginal US, abdominal computed tomography (CT) and abdominal MRI. Fine needle aspiration must be avoided as the risk of perforation is high that will lead to dissemination of the mucinous material causing a serious complication called pseudomyxoma peritonei. Laparotomy is superior on laparoscopy as the risk of perforation is lower in laparotomy. CONCLUSION: The presentation of AM is usually not specific, because of its anatomic position. Physicians should consider it in the differential diagnosis of persistent enlarging ovarian cyst or adnexal mass.