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Image of the Month—Quiz Case FREE

Tamer Akca, MD; Koray Ocal, MD; Ozgur Turkmenoglu, MD; Oner Bilgin, MD; Suha Aydin, MD
[+] Author Affiliations

Author Affiliations: General Surgery Department, Mersin University Medical Faculty, Mersin, Turkey.

Arch Surg. 2006;141(9):943. doi:10.1001/archsurg.141.9.943-a.
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A 57-year-old man was referred to our department from the state hospital with nausea and vomiting. He also had a lack of appetite and had lost weight (7 kg) during the previous 75 days. He had no abdominal pain, but his feces were small and spherical, and he could only defecate every other day. He had no medical or surgical treatment history.

Muscular defense or rebound tenderness was not determined on physical examination of the abdomen. However, a painless, 10 × 10-cm-diameter mass with a smooth surface was palpated from the periumbilical region and right lower quadrant to the suprapubic region. Auscultation of the intestines and digital rectal examination results were normal. His arterial blood pressure was 110/80 mm Hg and his pulse was 67 beats/min. His erythrocyte sedimentation rate was 12 mm/h (reference range, <5 mm/h) and his C-reactive protein level was 24 mg/L (reference range, 0-10 mg/L). There were no pathologic findings for other laboratory studies.

Abdominal ultrasonography revealed that the patient had diffuse, increasing parenchymal echogenicity of the liver, jejunal hypersecretion, and jejunal wall thickness at the umbilical level. There was some fluid collection at the interjejunal spaces. Computed tomography of the abdomen and pelvis showed that there was dilatation on fourth part of the duodenum, jejunum, and ileum. Fluid collection and wall thickness between mesenteric folds of the ileum at the umbilical level were detected. No luminal lesion was found, however. Amorphous calcifications approximately 1 to 1.5 cm in diameter were indicated at the caudal end of the mesentery near the ileocecal junction, anterior to the psoas muscle. Diagnostic tests revealed that the pelvic organs were normal. Radiological diagnosis was reported as mesenteritis or internal herniation. Colonoscopy findings for the patient were normal. Explorative laparotomy was planned for the patient after initial examinations.

Perioperative exploration showed that the distal part of the stomach and small intestine, as well as the colon and urinary bladder, were covered by a thick, dense fibrotic membrane. The fibrotic membrane on the small intestine was divided into 3 parts at the mesentery level (Figure 1). There was no obstruction at the colonic passage. There was an obvious decrease in small-intestine motility.

Place holder to copy figure label and caption
Figure 1.

Small intestine covered with fibrotic membrane.

Graphic Jump Location


A. Tuberculous peritonitis

B. Abdominal cocoon

C. Peritonitis carcinomatosa

D. Bacterial peritonitis


Place holder to copy figure label and caption
Figure 1.

Small intestine covered with fibrotic membrane.

Graphic Jump Location




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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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