Role of conservative management in tubercular abdominal cocoon: a case series

Sclerosing encapsulating peritonitis (Abdominal cocoon) is an uncommon cause of intestinal obstruction and tuberculosis is an important etiology. Appropriate management of this entity is still uncertain.

We did a retrospective analysis of patients with abdominal cocoon who were seen over a two year period at a tertiary care center in North India. We included patients with tubercular abdominal cocoon (TAC) who were managed primarily with antitubercular therapy in the present report. The diagnosis of TAC was made using combination of criteria (radiological or surgical findings of cocoon with evidence of tuberculosis in form of microbiological, histological or biochemical evidence). The clinical presentation, outcome and need for surgery for these patients were retrieved from the records of these cases maintained in a database.

Of 18 patients with abdominal cocoon, 15 patients had underlying tuberculosis. The median age was 28 years (interquartile range 24) and 12 (80%) were males. Three patients had confirmed tuberculosis on basis of microbiological evidence. All had abdominal pain for 1-9 months, and 11 had intestinal obstruction. Twelve patients had positive Mantoux test, none had HIV. Pulmonary tuberculosis was noted in four patients, pleural in five, splenic and intestinal in two each, hepatic and mediastinal lymph-nodal in one each. Thirteen patients were started on usual 4-drug anti-tubercular therapy (ATT) while two cirrhotics needed modified ATT. Three patients were on steroids with ATT and all three improved. One patient was lost to follow up. Of the rest 14 patients, 2 underwent surgery, 1 at initial presentation while another after 4 months of ATT. Overall five patients developed intestinal obstruction while on ATT, one needed surgery and one died of liver failure while others improved with conservative means.

TAC can be managed conservatively in a subset of patients.