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JAMA Surgery Clinical Challenge
November 2014

The Cocoon Abdomen

Author Affiliations
  • 1Department of Surgical Oncology, John Wayne Cancer Institute, Santa Monica, California
  • 2Department of Pathology, Providence Saint John’s Health Center, Santa Monica, California
JAMA Surg. 2014;149(11):1201-1202. doi:10.1001/jamasurg.2014.81

An 85-year-old man with a history of occupational exposure to asbestos presented with 1 week of nausea and vomiting without any bowel function. He reported only mild abdominal pain. The patient denied any history of abdominal surgery. On examination, he was mildly distended and tender focally on the right side. In the emergency department, a nasogastric tube was placed, yielding a moderate amount of dark, foul-smelling output. Laboratory results were significant for a white blood cell count of 13 300/μL (to convert to ×109 per liter, multiply by 0.001) (bands 20%). A contrast-enhanced computed tomographic scan of the abdomen and pelvis demonstrated dilated small intestine (measuring up to 4.7 cm), with air-fluid levels extending to the terminal ileum (Figure 1A and B). The entire colon was collapsed. There were several loops of normal-caliber bowel proximal to the area of concern. The decision was made to take him to the operating room for exploration given the lack of any previous abdominal surgical procedures and no other explanation for his symptoms. Intraoperatively, a large portion of the small intestine was involved in dense adhesions. After performing careful lysis on the distal involved bowel, a tightly coiled and twisted segment was encountered (Figure 1C). At this point, further attempts to separate loops of small intestine would have been difficult, and the decision was made to resect this segment (approximately 110 cm) and perform a primary anastomosis.