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Peritoneal loose body with boiled egg appearance Arwikar AS, Chavarkar S, Sudhamani S, Mukharji S



How to cite this article:
Arwikar AS, Chavarkar S, Sudhamani S, Mukharji S. Peritoneal loose body with boiled egg appearance. Indian J Pathol Microbiol 2022;65:511-2




Dear Editor,

We would like to draw attention to one interesting entity which shows boiled egg appearance grossly.

A 65-year-old female came with complaints of vomiting and abdominal pain for 4 days. CT scan showed a free ovoid mass measuring 1.5 cms in diameter with a central heterogenous calcification and peripheral soft tissue was noted in the peritoneal cavity with the diagnosis of calcified mesenteric mass and uncomplicated left Morgagni hernia. Patient underwent exploratory laparotomy. Hernia was repaired and excision of an oval shaped, white, firm body which was found lying freely in the abdominal cavity without any attachment to omentum or mesentery was done.

Grossly, a white, firm ovoid mass with a smooth exterior was noted, 1.5 cms in diameter. The cut section, revealed a peripheral white area with central greasy yellowish portion resembling a boiled egg [Figure 2].

Figure 2: Gross of peritoneal loose body (cut surface) shows peripheral white and central yellow portion resembling a boiled egg

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Microscopically, the ovoid mass revealed a peripheral part composed of laminated strands of fibrinoid substance with proteinaceous material. Central area showed saponified fat and areas of dystrophic, granular calcification. A diagnosis of peritoneal loose body was made [Figure 1], [Figure 1]a.

Harrigan first described the free-lying appendix epiploicae. In the year 1863, Virchow put forth the theory of formation of loose peritoneal body. He postulated that, increased fat content of appendices epiploicae led to a gradual obliteration of the blood vessels of the pedicle followed by torsion, strangulation and necrosis of the epiploic appendages due to the inflammation caused by intra-abdominal adhesion, volvulus, intestinal obstruction or intestinal perforation. According to him the pedicle would ultimately atrophy and separate from the colon giving rise to peritoneal loose body.[1]

Peritoneal loose bodies (PLB) which show a “boiled egg ” appearance are small lesions and when more than 5 cms, are referred to as giant PLB. They are rare and very few cases are reported.[2]

Patient presents in 5th – 7th decade with male to female ratio 18:4.[3]

The largest PLB was reported by Mohri et al., in 2007 measuring 95 × 86 mm in maximum diameter.[4]

It is believed that after the saponification of the appendix epiploica, the exudative protein rich serum fluid accumulates around it and increased temperature of the peritoneal cavity gives it a boiled egg appearance. In some cases, they may attach to the omentum and receive blood supply from it; wherein they are called parasitized peritoneal body.

X-ray findings of a calcified abdominal mass, which moves with change in position of the patient is highly suspicious of PLB.[2] CT scan [Figure 3] reveals a round to oval mass with calcification. MRI findings reveal a low intensity mass on both T1 and T2 weighted images and it is believed to have same intensity as that of collagen fiber or muscle.[5]

Figure 3: CT scan: A mobile ovoid shaped mass measuring 2 × 1.8 cm with few hyperechoic calcific foci

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PLB should be differentiated from: sclerosing mesenteritis, calcifying fibrous pseudotumour, tuberculous and other granulomatous peritonitis, disseminated peritoneal leiomyomatosis and lymph node calcifications.

Treatment is surgical and no follow-up is required.[3]

Pre-operative diagnosis of peritoneal loose body is difficult, and a high index of suspicion is required. It is important for pathologists to be aware of the morphological entity to prevent overtreatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

   References   Top


1.
Rajbhandari M, Karmacharya A, Shrestha S. Pathological diagnosis of peritoneal loose body: A case report. Gastrointestinal Pathology.  Back to cited text no. 1
    
2.
Sewkani A, Jain A, Maudar K, Varshney S. ‘Boiled egg’ in the peritoneal cavity-a giant peritoneal loose body in a 64-year-old man: A case report. J Med Case Rep 2011;5:297.  Back to cited text no. 2
    
3.
Zhang H, Ling Y-Z, Cui M-M, Xia Z-X, Feng Y, Chen C-S. Giant peritoneal loose body in the pelvic cavity confirmed by laparoscopic exploration: A case report and review of literature. World J Surg Oncol 2015;13:118.  Back to cited text no. 3
    
4.
Mohri T, Kato T, Suzuki H. A giant peritoneal loose body: Report of a case. Am Surg 2007;73:895-6.  Back to cited text no. 4
    
5.
Kim HS, Sung JY, Park WS, Kim YW. A giant peritoneal loose body. Korean J Pathol 2013;47:378-82.  Back to cited text no. 5
    



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Asawari S Arwikar
2A/601, Bhavini Enclave, 44 ft D. P. Road, Mulund East, Mumbai, Maharashtra – 400 081
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPM.IJPM_1392_20

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[Figure 1], [Figure 2], [Figure 3]

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