Sclerosing encapsulating peritonitis after orthotopic liver transplantation

Background: The etiology of abdominal cocoon (a rare cause of intestinal obstruction) is unknown. It has occurred in adolescent girls, cirrhotic patients after peritoneal-venous shunting, and patients undergoing peritoneal dialysis. We report our experience with patients after orthotopic liver transplantation (OLT). Methods: Five patients (4 male, 1 female, aged 16 to 57 years) underwent OLT (3 whole liver, 2 right lobe grafts) and subsequently developed abdominal cocoon. Results: All developed pyrexia by 66 ± 21 hours posttransplant. Additional symptoms (epigastric discomfort and intermittent vomiting) occurred 12 ± 10 days later. Bacterial peritonitis was confirmed by microbiology in 2 cases and diagnosed by exclusion in the others. C-reactive protein levels were persistently elevated in all patients (35 to 82 mg/L). While abdominal CT consistently demonstrated marked ascites with the small intestine confined to a particular area of the abdomen, intestinal contrast studies and ultrasound were not diagnostic. All patients underwent surgical removal of the cocoon membrane by 58 ± 22 days after transplant. Conclusions: Sclerosing peritonitis may complicate liver transplantation and occurs because of low-grade intra-abdominal sepsis.