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235 ABDOMINAL COCOON COMPLICATING REPEAT LIVER TRANSPLANTATION R Lee1, C Toso2, D Bigam2, KW Burak1 BACKGROUND: 'Abdominal cocoon' or sclerosing encapsulating peritonitis (SEP) is an extremely rare condition in which the small bowel becomes encased in a fibro-collagenous membrane. This entrapment leads to compression of the bowel and intestinal obstruction. The pathogenesis of SEP remains unknown, but it has been associated with retrograde menstruation, beta-blocker usage, peritoneal dialysis and peritoneal-venous shunts in cirrhotic patients. To date, there are only 3 previous reports (7 patients) of SEP complicating liver transplantation (LT).
1University of Calgary Liver Unit, Calgary; 2University of Alberta Liver Transplant Program, Edmonton, Alberta
CASE REPORT: This 27 y.o. male was diagnosed with autoimmune hepatitis in 1995 and primary sclerosing cholangitis (PSC) 4 years later. He underwent live donor LT in June 2001, but due to poor graft function was re-transplanted with a cadaveric liver in July 2001. Recurrence of PSC was documented in December 2002, which rapidly progressed and resulted in a third LT in March 2006. Two months later, he developed severe, persistent abdominal pain, anorexia and bloating. There was no history of fevers or chills and he had no past history of spontaneous bacterial peritonitis (SBP). Investigations including ultrasounds, MRI, SBFT, colonoscopy and gastroscopy failed to identify a definitive cause for his symptoms. A subsequent CT scan was highly suggestive of SEP (loops of small bowel were clustered in the right lower quadrant and surrounded by a thin membrane). High dose oral corticosteroids were started and his tacrolimus was switched to sirolimus for its anti-fibrotic properties; however, this medication was not tolerated (cytopenia). Ultimately in August 2006, the diagnosis of abdominal cocoon was confirmed at laparotomy and lysis of adhesions was performed. Although, he would later require repeat surgery for wound dehiscence, the patient is now doing well with dramatic improvement in his symptoms.
DISCUSSION/CONCLUSIONS: SEP is a very rare complication of LT (0.27% at King's College) and is usually seen following episodes of SBP. The etiology is unclear, but it is associated with chronic irritation of the peritoneal cavity. Our patient had no history of SBP but we hypothesize that his multiple LT surgeries put him at risk for this rare complication. Although immunosuppression has been used, treatment of SEP is most often surgical. SEP should be considered in LT recipients with obstructive symptoms and/or unexplained abdominal pain.