 Today, we will be discussing a special condition in the abdomen, which is known as abdominal cocoon. So, what is abdominal cocoon? It is total or partial encapsulation of the small bowel by fibrocannous membrane with local inflammatory infiltrates leading to acute or chronic bowel obstruction. Histologically, peritoneum shows proliferation of the fibro-connected tissue inflammatory infiltrates and dilated lymphatics. Several other names are there of this condition such as peritonitis, chronic fibrosis, incapsulata, sclerosing, encapsulating, peritonitis, sclerosing, peritonitis, incapsulating, peritonitis etc. Coming to the etiology, they are classified as either primary or secondary. In primary form, etiology is not exactly known, but various hypotheses are proposed. First of it is subclinical peritonitis. The patient may have some form of peritonitis which is not so florid and there may not be some clinical presentation and it may have led to the formation of a cocoon. The other is retrograde menstruation. In young girls, few years after the minnage, retrograde menstruation can occur inside the peritoneal cavity which can inside chemical peritonitis. This is associated with viral peritonitis and it can lead to formation of a cocoon. Some congenital predisposition to this entity is also suspected and reported in view of some of the cases with greater momentum hyperplasia and mesentric vessel malformation seen in few of these patients. Coming to the secondary causes and predispositions, the most common cause is drugs. Peritoneal dialysis with multiple drugs is one of the most important cause of abdominal cocoon formation. Peritoneal installation of drugs and chemotherapy, use of providone iodine for the abdominal washout, beta-adryneurotraic blockers, practolol which can inside peritoneal inflammation are also other important causes. Shunts and procedures such as VP shunt, peritoneal venous shunt in cirrhotics, leave-in shunt for the refractory sitease, previous abdominal surgery or peritonitis, liver transplantation and multiple other abdominal surgeries are also important cause. Some of the diseases which involves the peritoneum such as tuberculosis, sarcoidosis, pelvic inflammatory disease, recurrent peritoneitis, family mediterranean fever, SLE, protein S deficiency are also important cause of cocoon formation. Some of the tumors such as gastrointestinal malignancy, luteinized ovarian thicomas, leo myometer of the uterus endometriotic cysts or tumors of the ovary and dermal cyst rupture which can also inside associated peritoneitis can also lead to the formation of the abdominal cocoon. Coming to the clinical features, there are usually the features of recurrent acute, sub acute or chronic small bowel obstruction. Recurrent abdominal pain, nausea and vomiting are usual presenting symptoms. The patient may also present with anorexia, weight loss, malnutrition, palpable abdominal mass and abdominal distention. This entity is common in tropics and mainly in the young adolescent females who are affected more. However, males, children, premenopausal females and persons in non-tropical areas are also affected by this entity. There are three types according to the extent of ankencine membrane according to this particular reference. In type 1, the membrane encapsulates only the intestines and the two partially. In type 2, membrane encapsulates the intestine almost entirely and completely whereas in type 3, the membrane encapsulates the intestines entirely along with some other organs such as appendix, cecum, ascending colon, ovary, etc. Coming to the imaging features, on plain radiograph, features of bowel obstruction are seen with dilated bowel loops and air fluid levels. On barium studies, serpentine configuration of the dilated small bowel within the cocoon or confined region are seen. This leads to something called as cauliflower sign and both proximal small bowel dilation is seen with increased digit time. On sonography, multiple confluence small bowel loops are seen with which are encased in thick hypoechoic membrane which is made visible by minimal ascites. B bowel arranged in concertina shape with narrow posterior base having the overall appearance of a cauliflower membrane are not well seen in absence of ascites. So this is typical cauliflower-like appearance on sonography and one can see a loculated appearance on barium studies with so-called cauliflower sign. On CT scan which forms the mainstay of the diagnosis, one can see basically the signs of peritonitis, signs of bowel obstruction and multiple adhesions. So basically on CT scan one can see adherent small bowel loops encased within a thick enhancing peritonial membrane. Demonstration of an enhancing peritonial membrane is very important for this diagnosis. There can be retraction of the mesentry which can lead to characteristic appearance of the tethered small bowel loops which is called as gingerbread men's sign. According to the mesentry may also be sclerosed and retracted. There are signs of obstruction, agglutination and fixation of the intestinal loops, mural thickening, ascites and local fluid collections, peritonial thickening with enhancement, peritonal intestinal mural calcification and reactive adenopathy which may be seen both in mesentry, retroperitonium and other abdominal pelvic regions. MRI also shows similar findings, this is the case of MRI which in which we can see multiple small bowel loops which are encased in a membrane like structure. This is the first case, this is 17 year old girl who came with abdominal distention and features of obstruction. Positive oral contrast was given and we can see this multiple small bowel loops which are encased in, this is the membrane like structure. So this is abdominal cocoon formation and one can see the proximal bowel loops are dilated. But the loops inside the cocoon do not get that much of opportunity to get dilated because they are bound by the encasing membrane. This is the second case, a 32 year old man with pulmonary cox and plural calcification. We can see the plural calcifications here and also loss of lung volume on right side with multiple infiltrates in the lungs. This patient present with acute abdomen and CT scan showed small bowel loops encased by membrane with loculated acetase, mesentric and retroperitonal adenopathy and surgery and subsequent histopathology confirmed coxytology. So what we can see is multiple small bowel loops which are encased in this membrane like structure here, here and here. This is the third case, a 28 year old man with abdominal pain. However abdominal bowel loops are clumped here and one can see a partial membrane like structure all around this. Minimal acetase and inflammatory reaction were also seen. One can see there are no abnormality seen on the abdominal angiogram and on surgery the diagnosis of cocoon was confirmed. Why we need to obtain the angiography because we need to differentiate from other differential diagnosis of clumped abdominal bowel loops such as malrotation and other entities which may show some abnormality on CT angiography. This is a fourth case, a 13 year old girl which presented with abdominal pain since one month with increased over last nine days. And CT scan shows multiple bowel loops which are encased by membrane, this is where the membrane and they produce something S shaped here are the membranes and inflammatory changes and signs of peritonitis as well. Multiple mesentric nodes were seen. The angiogram was normal and findings of cocoon were confirmed at surgery. This is the fifth case, a 58 year old lady who presented with encased colonic loops with internal feces also we can see there is adjacent acides and membrane like structures all around the uterus is pushed anteriorly. One can see this cocoon like appearance and membrane is also seen here. This is a sixth case, a 22 year old girl with abdominal pain and showing bowel encased by membrane. So, these are the clumb over loops and one can see this membrane all around. This is the membrane, this is the membrane. This patient who is 59 year old patient with chronic renal failure and he was put on chronic peritonal dialysis with calcified cocoon. The walls of the membranes which forms the cocoon are calcified and when you see calcified walls of the cocoon it is more likely related to chronic peritonal dialysis. This is the tenth case, we can see multiple clumped bowel loops with adjacent membrane. Here is also abdominal membrane, clumped bowel loops, clumped bowel loops but what is more important is to see that there is defect in the anterior abdominal wall through which it opens externally and it is suggestive of enterocutinous fistula formation. Abdominal cocoon can lead to intra-abdominal infections, enterocutinous fistula formation, perforated bowel, bowel necrosis and gangrene formation. There are multiple differential diagnosis, usually the hallmark is that multiple clumped bowel loops are seen in this entity which are encased by surrounding membrane. Vascular appearance is sometimes seen in peritonal encapsulation which is a developmental anomaly where small bowel is encased in thin accessory membrane which is derived from the yolk sac and during 12th week of gestation. It may be associated with mid-gut mal rotation and vascular anomaly. So that is why it is important to also look at the miscentric vessels and CT angiography in these patients. Like cocoon these patients are mostly asymptomatic, they are found incidentally during the surgery and they are usually present late in life. Another differential diagnosis is internal hernias, usually only with the exception of left periodal hernia most of these internal hernias do not have membrane around it but they may show multiple displaced crowded and anguished miscentric vessels adjacent to multiple clumped bowel loops. So that may be confused with abdominal cocoon. The another entity called as chronic idiopathic intestinal pseudo obstruction is also to be considered and CT scan shows distinction of small and large bowel loops with no membrane like sac. Luminous interception also do not show any adjacent membrane and simple localized peritoneal adhesions also will be only localized and not completely around all the dilated bowel loops. Usually treatment is by stripping of the membrane and with stripping intestinal release can be obtained. Subtotal excision of the membrane is also performed at times. At times internalizes with small bowel intubation and bowel resection may have to be performed if part of the bowel is non viable. Adjacent adhesolol isis may be required in many cases. Exploratory reprotomy with postoperative medical treatment in patients with high perforative risk is also recommended. A special mention about treatment in patient with peritoneal dialysis. Incidents of peritoneal sclerosis in patients on peritoneal dialysis at 3, 5 and 8 years is reported at 0.3, 0.8 and 3.9 percent. So basically incidence of peritoneal sclerosis increases in patients with peritoneal dialysis. Unlike other etiologies, cocoon formation in patients with peritoneal dialysis have poor progress with reported early deaths and surgery carries high mortality in these patients. So basically in conclusion, although the final diagnosis of abdominal cocoon is usually made based on operative and histopathological findings, radiologist should be aware of this entity to make a definitive preoperative diagnosis which is best made on city and sometimes on sonography and barium studies and thus helping treatment of these patients. Thank you.