International Journal of Clinical & Medical Images

Clinical Image A 56-year-old male presented with abdominal pain, vomiting and peritoneal irritation signs on physical examination. He had history of IgA nephropathy in peritoneal dialysis since fourteen years ago with multiple episodes of bacterial peritonitis responding to intraperitoneal antibiotics. Void residual urine output. His peritoneal permeability was high requiring automated peritoneal dialysis with elevated glucose load for appropriate volume overload management. He refused hemodialysis repeatedly. In the last year the patient reported anorexia, weight loss and several minor episodes of abdominal pain accompanied by constipation or diarrhea that were blamed on a known diverticular disease. In admission the peritoneal effluent was clear. A CT of abdomen showed diffuse thickening of the peritoneum with linear calcifications and bands of fibrosis that were arranged between the loops of small intestine and forming several compartments which were confined. The laparotomy showed a peritoneum of “carapacelike” appearance (Figure 1), brownish, with a thick fibrous cover that included all intestinal loops (Figures 2 and 3) suggestive of abdominal cocoon due to a sclerosing encapsulating peritonitis. Treatment with adhesiolysis, antibiotics, parenteral nutrition, tamoxifen and hemodialysis was unsuccessful; patient died ten days later because of septic shock.