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The use of computed tomography in the diagnosis of abdominal cocoon

  • Author Footnotes
    1 Contributed equally.
    ,
    Author Footnotes
    2 Conceived, reporting the radiological findings.
    Ujjwal Gorsi
    Footnotes
    1 Contributed equally.
    2 Conceived, reporting the radiological findings.
    Affiliations
    Department of Gastroenterology, Radiodiagnosis and Imaging and Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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  • Author Footnotes
    1 Contributed equally.
    ,
    Author Footnotes
    3 Reporting the radiological findings, manuscript drafting and revision.
    Pankaj Gupta
    Footnotes
    1 Contributed equally.
    3 Reporting the radiological findings, manuscript drafting and revision.
    Affiliations
    Department of Gastroenterology, Radiodiagnosis and Imaging and Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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  • Author Footnotes
    4 Clinical care, manuscript drafting, revision and approval.
    Harshal S. Mandavdhare
    Footnotes
    4 Clinical care, manuscript drafting, revision and approval.
    Affiliations
    Department of Gastroenterology, Radiodiagnosis and Imaging and Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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  • Author Footnotes
    5 Clinical care of the patients, manuscript approval.
    Harjeet Singh
    Footnotes
    5 Clinical care of the patients, manuscript approval.
    Affiliations
    Department of Gastroenterology, Radiodiagnosis and Imaging and Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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  • Author Footnotes
    6 Clinical care of the patients, manuscript approval.
    Usha Dutta
    Footnotes
    6 Clinical care of the patients, manuscript approval.
    Affiliations
    Department of Gastroenterology, Radiodiagnosis and Imaging and Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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  • Author Footnotes
    7 Conceived, collected clinical data, clinical care of the patients, manuscript drafting, revision and approval.
    Vishal Sharma
    Correspondence
    Corresponding author at: Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
    Footnotes
    7 Conceived, collected clinical data, clinical care of the patients, manuscript drafting, revision and approval.
    Affiliations
    Department of Gastroenterology, Radiodiagnosis and Imaging and Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
    Search for articles by this author
  • Author Footnotes
    1 Contributed equally.
    2 Conceived, reporting the radiological findings.
    3 Reporting the radiological findings, manuscript drafting and revision.
    4 Clinical care, manuscript drafting, revision and approval.
    5 Clinical care of the patients, manuscript approval.
    6 Clinical care of the patients, manuscript approval.
    7 Conceived, collected clinical data, clinical care of the patients, manuscript drafting, revision and approval.

      Highlights

      • Tuberculosis is an important cause of abdominal cocoon in endemic regions.
      • Computed tomography can help in making a diagnosis of abdominal cocoon and may help avoid surgery.
      • The CT signs could include the cauliflower sign, concertina pattern and the novel Bottle Gourd sign.
      • The Bottle Gourd sign seems to be specific for intestinal obstruction in patients with abdominal cocoon.

      Abstract

      Background

      Literature on the diagnosis of abdominal cocoon using computed tomography (CT) outside the setting of continuous ambulatory peritoneal dialysis is sparse.

      Methods

      We did a retrospective analysis of contrast enhanced CT done for patients treated for abdominal cocoon. The clinical features, radiological findings, underlying etiology and outcomes were recorded.

      Results

      Of the 22 patients analyzed, 19 had tuberculosis, 2 had malignancy and 1 was idiopathic. The basis of diagnosis of cocoon was CT in 18 and CT and surgery in 4. Types 1, 2 and 3 cocoon were found in 3 (13.63%), 6 (27.27%) and 13 (59.09%) respectively. The bowel findings were clumped loops in 21 (95%), inter-bowel fluid in 13 (59%), bowel wall thickening/enhancement in 6 (27%) and stricture in 1 (5%). Peritoneal thickening and nodularity were seen in 14 (64%) and 2 (9%) while omental thickening, nodularity and mass in 9 (41%), 5 (21%) and 1 (5%). Cauliflower sign was seen in 14 (64%), concertina pattern in 5 (23%) and Bottle Gourd sign in 6 (23%) patients. Of 12 with imaging done during episode of IO, 11 (92%) had cauliflower sign, 4 (80%) had concertina appearance and 6 (100%) had bottle gourd sign. Post treatment weight gain with anti-tubercular therapy was seen in 14 (63.63%), resolution of ascites in 12 (54.54%) and 2 patients had complete resolution of cocoon on repeat imaging.

      Conclusion

      CT is a valuable tool for pre-operative diagnosis of abdominal cocoon. The classical described signs are seen more frequently in patients with IO.

      Keywords

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