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Special Feature
September 1, 2006

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations: General Surgery Department, Mersin University Medical Faculty, Mersin, Turkey.

Arch Surg. 2006;141(9):943. doi:10.1001/archsurg.141.9.943-a

A 57-year-old man was referred to our department from the state hospital with nausea and vomiting. He also had a lack of appetite and had lost weight (7 kg) during the previous 75 days. He had no abdominal pain, but his feces were small and spherical, and he could only defecate every other day. He had no medical or surgical treatment history.

Muscular defense or rebound tenderness was not determined on physical examination of the abdomen. However, a painless, 10 × 10-cm-diameter mass with a smooth surface was palpated from the periumbilical region and right lower quadrant to the suprapubic region. Auscultation of the intestines and digital rectal examination results were normal. His arterial blood pressure was 110/80 mm Hg and his pulse was 67 beats/min. His erythrocyte sedimentation rate was 12 mm/h (reference range, <5 mm/h) and his C-reactive protein level was 24 mg/L (reference range, 0-10 mg/L). There were no pathologic findings for other laboratory studies.

Abdominal ultrasonography revealed that the patient had diffuse, increasing parenchymal echogenicity of the liver, jejunal hypersecretion, and jejunal wall thickness at the umbilical level. There was some fluid collection at the interjejunal spaces. Computed tomography of the abdomen and pelvis showed that there was dilatation on fourth part of the duodenum, jejunum, and ileum. Fluid collection and wall thickness between mesenteric folds of the ileum at the umbilical level were detected. No luminal lesion was found, however. Amorphous calcifications approximately 1 to 1.5 cm in diameter were indicated at the caudal end of the mesentery near the ileocecal junction, anterior to the psoas muscle. Diagnostic tests revealed that the pelvic organs were normal. Radiological diagnosis was reported as mesenteritis or internal herniation. Colonoscopy findings for the patient were normal. Explorative laparotomy was planned for the patient after initial examinations.

Perioperative exploration showed that the distal part of the stomach and small intestine, as well as the colon and urinary bladder, were covered by a thick, dense fibrotic membrane. The fibrotic membrane on the small intestine was divided into 3 parts at the mesentery level (Figure 1). There was no obstruction at the colonic passage. There was an obvious decrease in small-intestine motility.

Figure 1. 
Small intestine covered with fibrotic membrane.

Small intestine covered with fibrotic membrane.

What Is the Diagnosis?

A. Tuberculous peritonitis

B. Abdominal cocoon

C. Peritonitis carcinomatosa

D. Bacterial peritonitis