a 42-year - old libyan female patient had been diagnosed as ca rectum ( t3n1m0 ) and had undergone  r0 a - p resection on 31 may 2009 in tunisia . for this reason , she had received chemotherapy and adjuvant radiotherapy after the surgery . in the immediate post - operative period , she had an episode of peritonitis which was treated conservatively . now , she presented to the surgical out - patients ' department with acute intestinal obstruction . an erect abdominal x - ray showed dilated small bowel loops with multiple fluid levels . ultrasound showed dilated small bowel loops with sluggish peristalsis and a thickened , irregular  sac - like structure in the midline in pelvis encasing small bowel loops ( fig . ct scan and mri had already been done in another hospital and showed congregated small bowel loops in the pelvis encased in a thick capsule with dilated small bowel loops ( figs . 2 and 3 ) . , it was found that a considerable length of the distal small bowel 30-cm proximal to the ileocecal valve was encased in a whitish thickened membrane ( fig . the patient had an uneventful post - operative period and was discharged from the hospital on the seventh post - operative day . t2w axial mr image shows encased bowel loops in pelvis . per - operative image showing the encapsulated bowel loops . sep is a rare condition of unknown cause in which intestinal obstruction results from the encasement of variable lengths of bowel by a dense fibrocollagenous membrane that gives the appearance of a cocoon the condition is not often suspected pre - operatively and the diagnosis is usually made at laparotomy . a history of previous abdominal surgery or peritonitis , chronic ambulatory peritoneal dialysis , and the prolonged use of practolol have been implicated as causative factors . the pre - operative diagnosis is difficult because of its non - specific imaging findings and reports are few in the literature on its radiologic imaging findings . various abdominal disorders ( such as tuberculosis , sarcoidosis , familial mediterranean fever , gastrointestinal malignancy , protein s deficiency , liver transplantation , fibrogenic foreign material , and luteinized ovarian thecomas ) are the other rare causative factors . abdominal distension , pain and vomiting , and presence of a soft non - tender mass at abdominal palpation , are the clinical features that may help in the pre - operative diagnosis of sep . in the appropriate clinical setting , recognition of the entire dilated small bowel at the center of the abdomen and encased within a thick fibrocollageneous membrane , as though it were in a reported a case of sep associated with liver cirrhosis and complicated by diffuse , large b cell lymphoma ( 1 ) . there are reports of perforation of cocoon , particularly in immune - compromised patients which carries a high risk of mortality . bani - hani et al . have reported perforation complicating tuberculous cocoon in immune competent patients ( 2 ) . multidetector row ct is invaluable for pre - operative diagnosis of this condition and shows typical features of congregated , small bowel loops confined to a single area and encased in a thick membrane ( 3 ) . it has been reported in the literature to complicate liver transplantation ( 5 , 6 ) . surgery is mandatory in all the cases and involves excision of the thick membrane and lysis of adhesions ( 7 ) . we conclude that sep is a rare complication of abdominal surgery or peritoneal dialysis and should always be considered in differential diagnosis of such patients presenting with intestinal obstruction . multidetector row ct is the best modality for pre - operative diagnosis and planning elective surgery . the authors have not received any funding or benefits from industry to conduct this study .
sclerosing encapsulating peritonitis ( sep ) is a rare but serious complication of abdominal surgery , recurrent peritonitis , and continuous ambulatory peritoneal dialysis with a high morbidity and mortality . 
 the etiology of this condition is largely unknown . 
 diagnosis is usually established at laparotomy in patients with recurrent attacks of non - strangulating , small bowel obstruction . 
 we report a case of a patient who presented with intestinal obstruction and who showed typical ct findings of sep which was diagnosed pre - operatively on a ct scan and confirmed at surgery . 
 the interest of this case lies in its rarity and difficult pre - operative diagnosis .