Encapsulated peritoneal sclerosis (EPS) is life threatened serious condition that has variety of multifactorial etiologic causes. Although EPS previously known as sclerosing peritonitis, peritoneal inflammation is not always present. Patient complaints like abdominal pain and, vomiting are not different from other causes of intestinal obstruction. Abdominal contrast enhanced computer tomography (CT) is the preferred imaging modality to show abnormal thickened peritoneal membrane and clumped dilated bowel loops ⁴. Our aim in this article is to present a patient with abdominal EPS after caustic digestion that a rare cause of EPS.

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Figure 1 a: Abdominal enhanced CT showed that clustered, dilated intestinal loops and peritoneal thickening.in axial image

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Figure 1 a-b: Abdominal enhanced CT showed that clustered, dilated intestinal loops and peritoneal thickening in coronal image (arrows)

EPS can appear idiopathic or secondary to abdominal disorders and other etiologic factors. The major factors related to abdominal cocoon include peritoneal dialysis, ventriculoperitoneal shunts, tuberculosis, renal or liver transplantation, use of practolol, and malignancies.

The clinical presentation is not specific. The initial symptoms like abdominal pain, nausea and vomiting is associated with altered gut motility and peritoneal permeability ⁴.

Kitchen liquid detergents are caustic household products that are classified as alkalis. Alkali substances transit the oropharyngeal mucosa and esophagus slowly. They have high viscosity and can cause liquefactive necrosis. Esophagus stenosis can occur later with sclerosis ². Although alkali ingestion causes upper gastrointestinal tract injury generally, these products can injury lower tract injury rarely ⁷. Household products contain strong alkali substances and low digestive injury can occur after drinking liquid detergents. In one experiment household alkali bleaches injected in rats intraperitoneal to start peritonitis, later rat’s blood was injected into the peritoneum. The chemical irritant caused peritonitis and injected blood clot was responsible for bringing visceral surfaces together with intestinal loops form of the cocoon. This experiment appears that fibrosis, inflammation and, coagulation is a primary reason for cocoon formation after chemical irritant exposure ⁸.

Abdominal X-rays, US, contrast enhanced CT and magnetic resonance imaging (MRI) can use to diagnose EPS. The radiograph can show dilated intestinal loops with air- fluid levels but this imaging has low sensitivity ⁹. CT has high sensitivity to detect clumping dilated small bowels with thickened peritoneum ¹⁰. CT also can show ascites, lymphadenopathy, and peritoneal calcifications.

EPS differential diagnosis includes congenital peritoneal encapsulation is a benign condition characterized by a thin accessory peritoneal membrane surrounding the small bowel. This condition is, however, asymptomatic and is usually diagnosed during unrelated surgery or radiologic examinations. Peritoneal carcinomatosis can demonstrate thickening and abnormal enhancement of the peritoneum, findings mimicking EPS. However, it is generally easy to differentiate the two conditions, because the thickening in peritoneal carcinomatosis is nodular with associated nodules in the omentum, the pouch of Douglas, and the serosal surfaces, with or without lymphadenopathy. Internal hernias may demonstrate abnormal clustering of bowel loops that may mimic the centrally displaced bowel loop pattern of EPS. However, it is usually possible to differentiate the two conditions at CT because of the absence of the soft-tissue mantle in internal hernias as well as the relatively fixed anatomic regions in which they occur.

Surgery or conservative medical therapy are two options to treat encapsulated peritoneal sclerosis. Traditionally surgery is the preferred way to both detect and treated EPS. Although CT scan helps to detect an intestinal obstruction, peritoneal thickening and loculated fluid collections, these findings are seen at the advanced stages of the disease. Early changes in disease can be observed with laparoscopy. The surgical procedure is the resection of the peritoneal membrane and adhesive bands ¹¹. Medical therapy can be used for patients without any sign of intestinal obstruction or inflammation. Immunosuppressants (corticosteroids) and renin-angiotensin-aldosterone system inhibitors may be effective.

In conclusion, although EPS is a benign process of intestinal obstruction, this condition is known as life threatening with a high fatality rate. EPS has various of causes and caustic ingestion is one of these. Radiological findings are important to diagnose this clinical entity.

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