Encapsulating Peritoneal Sclerosis: The Abdominal Cocoon

Manphool Singhal, Satheesh Krishna , Anupam Lal, Sabarish Narayanasamy, Amanjit Bal, Thakur D. Yadav, Rakesh Kochhar, Saroj K. Sinha, Niranjan Khandelwal, Adnan M. Sheikh

Author Affiliations

• From the Departments of Radiology (M.S., A.L., N.K.), Histopathology (A.B.), General Surgery (T.D.Y.), and Gastroenterology (R.K., S.K.S.), PGIMER, Chandigarh, India; and the Abdominal Imaging Section, Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, Ont, Canada (S.K., S.N., A.M.S.).
• Address correspondence to S.K., Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women’s College Hospital, University of Toronto, 610 University Ave, Toronto, ON, Canada M5G 2M9 (e-mail: satheeshkrishna.jeyaraj@utoronto.ca).

Published Online:Dec 7 2018https://doi.org/10.1148/rg.2019180108

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Abstract

Encapsulating peritoneal sclerosis is a serious disorder that results in cocooning of bowel loops within a thickened fibrocollagenous peritoneal membrane and can be diagnosed accurately with knowledge of the characteristic multimodality imaging appearances.

Encapsulating peritoneal sclerosis (EPS) is a rare but serious condition that results in (a) encapsulation of bowel within a thickened fibrocollagenous peritoneal membrane and (b) recurrent episodes of bowel obstruction. Although described by various names in the literature, the preferred term is encapsulating peritoneal sclerosis because it best describes the morphologic and histologic changes in this disorder. The etiology of EPS is multifactorial, with a wide variety of implicated predisposing factors that disrupt the normal physiologic function of the peritoneal membrane—prime among these factors being long-term peritoneal dialysis and bacterial peritoneal infections, especially tuberculosis. The clinical features of EPS are usually nonspecific, and knowledge of the radiologic features is necessary to make a specific diagnosis. The findings on radiographs are usually normal. Images from small-bowel follow-through studies show the bowel loops conglomerated in a concertina-like fashion with a serpentine arrangement in a fixed U-shaped configuration. US demonstrates a “cauliflower” appearance of bowel with a narrow base, as well as a “trilaminar” appearance depicted especially with use of high-resolution US probes. CT is the imaging modality of choice and allows identification of the thickened contrast material–enhanced abnormal peritoneal membrane and the encapsulated clumped bowel loops. In addition, CT can potentially help identify the cause of EPS (omental granuloma in tuberculosis), as well as the complications of EPS (bowel obstruction). Conservative medical treatment and surgical therapy early in the course of EPS have been used for management of the condition. The purpose of this article is to review the nomenclature and etiopathogenesis of EPS, describe the multimodality imaging appearances of EPS, including differentiating its features from those of other conditions mimicking EPS, and give an overview of management options.