{"paper_id":"0a0677fb-ce03-4b09-8bf1-70460e7bc1cf","body_text":"Przegl¥d menoP auzalny 2/2013\n163\nSummary\nEndometriosis is a common condition in many women of the child-bearing age. It affects approximately \n8-15% of the menstruating female population. Usually endometriosis can be found in the peritoneal cavity. \nEctopic foci can be located in a number of other organs, such as the lung, gall bladder, retroperitoneal space, \nstomach, small and large intestine and pancreas. It is found beyond the peritoneal cavity in 0.2% of the popula-\ntion. Endometriotic foci in the colon have already been discussed, however, there is a rare type of this condition \nthat imitates Crohn’s disease. This paper presents a long-term disease which was diagnosed and treated as \nCrohn’s disease. In the third year of treatment, colonic endometriosis was diagnosed correctly.\nKey words: endometriosis, Crohn’s disease, colon.\nStreszczenie\nOpisywany w niniejszej pracy przypadek jest o tyle ciekawy, że kolejne badania pacjentki przez 3 kolejne \nlata diagnostyki nie dały ostatecznego rozpoznania. Ze względu na postawioną przed 3 laty diagnozę – cho-\nroba Leśniowskiego-Crohna – pacjentkę leczono błędnie. Trudności w rozpoznaniu tej jednostki chorobowej \nstale występują. Endometrioza to częsta przypadłość wielu kobiet w wieku rozrodczym. Choroba dotyczy przede \nwszystkim kobiet, ale znane są przypadki endometriozy u mężczyzn z rakiem gruczołu krokowego. U kobiet \nwystępuje u ok. 8–15% miesiączkującej populacji. Najczęstszym umiejscowieniem zmian jest jama otrzewnej. \nW wielu innych narządach, takich jak płuco, pęcherzyk żółciowy, przestrzeń zaotrzewnowa, żołądek, jelito cien-\nkie i grube oraz trzustka, można rozpoznać ogniska ektopowe. Umiejscowienie poza jamą otrzewnej dotyczy \nwg danych z piśmiennictwa 0,2% populacji. Ogniska endometriozy w jelicie grubym już opisywano, ale rzadko-\nścią jest postać choroby, która imituje chorobę Leśniowskiego-Crohna. W pracy opisano pacjentkę z wieloletnią \nchorobą zdiagnozowaną i leczoną jako choroba Leśniowskiego-Crohna, u której dopiero po kilku latach leczenia \nrozpoznano prawidłowo endometriozę jelita grubego. Po prawidłowo przeprowadzonym procesie diagnostycz-\nnym leczeniem z wyboru jelitowej postaci endometriozy jest laparoskopowa resekcja jelita. Jest to technika \nogólnie dostępna, obarczona niewielką liczbą powikłań. Ostatnio ukazało się kilka prac na temat resekcji jelita \nze wspomaganiem robota.\nSłowa kluczowe: endometrioza, choroba Leśniowskiego-Crohna, okrężnica.\nEndometriosis of colon as a cause mimicking Crohn’s disease: a potential pitfall \nin diagnosis\nEndometrioza jelita grubego naœladuj¹ca chorobê Leœniowskiego-Crohna – potencjalny problem diagnostyczny\nJacek Śmigielski1, Beata Woźniak2, Marian Brocki1\n1Department of Thorax, General and Oncological Surgery, Medical University of Lodz, Poland; \nHead of Department: Prof. Marian Brocki MD, PhD \n2Department of Endoscopy, EndoTerapia, Lodz, Poland\nPrzegląd Menopauzalny 2013; 2: 163–165\nAddress for correspondence: \nJacek Śmigielski, Department of Thorax, General and Oncological Surgery, Medical University of Lodz, Żeromskiego 113, 90-549 Lodz, Poland,  \ntel. +48 42 639 35 21, e-mail: smiglo@mp.pl\nDOI: 10.5114/pm.2013.35079\nIntroduction\nEndometriosis is a common condition in many women \nof child-bearing age. Its most common site is the perito-\nneal cavity. Endometriotic foci can also be found in many \nother organs, such as the lung, urinary bladder, retroperi-\ntoneal space and alimentary tract [1-7]. However, the colon \nis the most common ectopic focus. Colonic endometriosis \nhas already been described but there is still a rare type \nof this condition that imitates Crohn’s disease. This work \npresents the case of a long-term disease that was first di-\n\nPrzegl¥d menoP auzalny 2/2013\n164\nagnosed and treated as Crohn’s disease. In the third year \nof observation, diagnostics and treatment, the disease \nwas recognised properly as colonic endometriosis.\nCase report\nA 50-year-old woman presented in hospital for sur-\ngery due to polypoid changes in the colon within 20-30 \ncm from the edge of the anus. For a few years, the patient \nhad complained of the pain in the abdomen with concur-\nrent diarrhoea and transient bleeding from the colon. Pre-\nviously, the patient was diagnosed (ultrasound, CT scan \n– NAD) and underwent colonoscopy with a histopatho-\nlogical examination (result no. 100165823/26.02.2009 – \nMorbus Crohn). The patient was treated for colitis for ap-\nproximately 3 years. The medication prescribed through \nthat period comprised mesalasine, corticosteride and \niron preparations. After about a year, another sample \nfor histopathological investigation was collected during \na routine examination on 08.10.2010 (Fig. 1). The result, \nno. 100314786/14.10.2010, was ambiguous – the mucosa \nwith a slight dysplasia in the enlarged glands. Numerous \nbranching capillaries were found in the lamina propria, \nFig. 3. Mucosal inflammation from 08.10.2012\neffusions and an inflammatory infiltration of granulo-\ncytes and lymphocytes, as well as oedema. No final di-\nagnosis was reported. The patient was still treated for \nan inflammatory bowel disease (IBD). Another endosco-\npy was performed on 30.11.2010 (Fig. 2). Histopathologi-\ncal result no. 3677/2010/KOL showed a slight oedema of \nthe mucosa and focal fibrosis of the lamina propria, as \nwell as a granulocytic infiltration with a crypt abscess. \nResults\nThe material could not be qualified to differentiate \nbetween an inflammation, adenoma, and secondary \nlesions or dysplasia. The patient was still treated for \nCrohn’s disease. The pain did not subside, the medica-\nments were continuously prescribed. The next histo-\npathological examination, no. 100429689/23/01/2012, \nwas conducted on 13.01.2012 (Fig. 3) and revealed \nthe mucosa and submucosa of the colon with endome-\ntriotic foci, which were mainly located within the sub-\nmucosa. Estrogen receptors (+), CD10 (+), CK7 (+) and \nCK20 (–) were found. The patient was referred for a sur-\ngical procedure at the local department.\nOn admission, her vital signs and physical exami-\nnation were normal. The laboratory studies were as \nfollows: WBC (white blood cells) 11 160/mm\n3, Hb (he-\nmoglobin) 12.8 g/dl, platelets 339 000/mm3, AST (aspar-\ntate transaminase) 20 IU/l, ALT (alanine transaminase) \n11 IU/l, alkaline phosphatase 68 IU/l, total bilirubin \n0.48 mg/dl, total protein 6.9 g/dl, albumin 3.5 g/dl, CRP \n(C-reactive protein) 18.0 mg/dl, and prothrombin time \nof 13.4 seconds. The viral marker tests, including HBsAg, \nanti-HBsAb and anti-HCV, were all negative. The pa-\ntient underwent a laparoscopic resection of the por-\ntion of the colon. No postoperative complications were \nnoticed. Two days following the operation, the patient \nwas released from hospital for further monitoring at \nsurgical and gynaecological clinics. \nThe patient’s further recovery was uneventful.\nFig. 1. View of colonoscopy from 08.10.2010\nFig. 2. View of colonoscopy from 30.11.2010\n\n\nPrzegl¥d menoP auzalny 2/2013\n165\nDiscussion\nEndometriosis was first described by Shroen in \n1690, yet its signs and symptoms were discussed not \nearlier than in 1769 by Duff. Endometriosis is defined as \nan atypical hyperplasia endometrium outside the uter-\nine cavity [8]. Mainly, the disease affects women, how-\never, there have been some cases of endometriosis in \nmen with prostate cancer [9]. The disease can be found \nthroughout the length of both the small and large in-\ntestines [2-4, 10].\nA clinical examination and interview are crucial in \nthe diagnostics. In addition, ultrasound or CT scan of \nthe abdomen are performed. With the development of \nmodern techniques, endoscopic ultrasound and EUS – \nguided FNA are used in the diagnostics of the lesions \nlocated in the lower part of the colon [11]. In some cases, \nMultislice CT enteroclysis is used [12]. A proper diagnos-\ntic process is followed by a laparoscopic resection of \nthe colon, which is a method of choice in colonic en-\ndometriosis [13]. This technique is widely available and \nnot encumbered with many complications. Recently, \nthe results of several studies have been published on \nthe use of robotic surgery and robotic assisted surgery \n[14]. Although these techniques merely support the clas-\nsical laparoscopy, their results are very promising.\nThe presented case is interesting insofar that \nthe 3-year diagnostics could not provide a final diag-\nnosis. Throughout the 3-year-long diagnostic process \n(Crohn’s disease) the patient was subject to inappropri-\nate treatment. There are many descriptions in the lit-\nerature of forms of endometriosis that simulate other \ndiseases. Either through its symptoms and signs or its \nclinical picture, endometriosis can imitate other dis-\neases with similar signs and symptoms. Samet et al. \n[15] discuss colonic endometriosis, which perfectly imi-\ntates colon cancer: the lesion was not found to differ \nfrom the cancer under virtual endoscopy. Another ex-\nample of imitation can be seen in another case oppo-\nsite to the one described here. Teke et al. [16] presented \nthe case of a young woman with Crohn’s disease situ-\nated in the colon, with concurrent polyps that narrowed \nthe intestine and a regular monthly rectal haemor -\nrhage. In endoscopy, the picture showed endometrio-\nsis in this part of the colon. The patient was subject \nto hemicolectomy. The postoperative histopathological \nexamination excluded the preliminary diagnosis and \nconfirmed Crohn’s disease.\nDifficulties in diagnosing this disease entity are still \npresent, yet now they are not so often, possibly due to \nmore detailed diagnostics and histopathological exami-\nnations: a good example of this is the case presented \nwithin this study. The ultrasound and CT scans did not \nreveal any lesions. The picture revealed by endoscopy \nwas similar to the picture of a different bowel inflam-\nmation. Often histopathology did not provide any firm \nevidence. Detailed receptor tests facilitated a correct \ndiagnosis.\nAll in all, the diagnosis of endometriosis can cause \na tremendous difficulty even to an experienced en-\ndoscopist, gynaecologist, surgeon or pathologist. The di-\nagnostic process can be long while an individually con-\nducted examination may not provide an unequivocal \ndiagnosis. In each dubious case every possible diagnostic \nmethod, including a repetitive microscopic examination \nand surgery, should be incorporated. \nReferences\n1. Fang HY, Jan CI, Chen CK, et al. Catamenial pneumothorax due to bilat-\neral pulmonary endometriosis. Respir Care 2012; 57: 1182-5. \n2. Pisanu A, Deplano D, Angioni S, et al. Rectal perforation from endome-\ntriosis in pregnancy: Case report and literature review. World J Gastro-\nenterol 2010; 16: 648-51. \n3. Cirillo F, Vismarra M, Buononato M, et al. Endometriosis of the caecum \nand ileo-caecal valve. A case report and review of the literature. Chir Ital \n2008; 60: 603-6. \n4. Garg NK, Bagul NB, Doughan S, et al. Intestinal endometriosis – a rare \ncause of colonic perforation. World J Gastroenterol 2009; 15: 612-4. \n5. Kashyap P, Medeiros F, Levy M, Larson M. Unusual submucosal tumor in \nthe stomach. Diagnosis: Endometriosis. Gastroenterology 2011; 140: e7-8. \n6. Monrad-Hansen PW, Buanes T, Young VS, et al. Endometriosis of \nthe pancreas. J Minim Invasive Gynecol 2012; 19: 521-3. \n7. González-Longoria G, Mejía-Ovalle R, Salinas-Aragón E, et al. Perineal \nendometriosis with anal external sphincter involvement: a case-report. \nRev Gastroenterol Mex 2011; 76: 173-7. \n8. Evers JL. Endometriosis does not exist; all women have endometriosis. \nHum Reprod 1994; 9: 2206-9. \n9. Martin JD, Hauck AE. Endometriosis in the male. Am Surg 1985; 7: 426-30. \n10. Arévalo Suárez FA, Cerrillo Sánchez G. Appendicular endometriosis as \na finding in cases of acute appendicitis. 4 case reports. May 2nd na-\ntional hospital. Rev Gastroenterol Peru 2006; 26: 324-7. \n11. Leyden J, Winter DC, Clarke E, O'Keane C. Endoscopic ultrasound and \nEUS-guided FNA in the diagnosis of rectal endometriosis. Ir Med J 2009; \n102: 301. \n12. Biscaldi E, Ferrero S, Fulcheri E, et al. Multislice CT enteroclysis in the di-\nagnosis of bowel endometriosis. Eur Radiol 2007; 17: 211-9. \n13. Campagnacci R, Perretta S, Guerrieri M, et al. Laparoscopic colorectal \nresection for endometriosis. Surg Endosc 2005; 19: 662-4. \n14. Daraï E, Ballester M, Chereau E, et al. Laparoscopic versus laparotomic \nradical en bloc hysterectomy and colorectal resection for endometriosis. \nSurg Endosc 2010; 24: 3060-7. \n15. Samet JD, Horton KM, Fishman EK, et al. Colonic endometriosis mimick-\ning colon cancer on a virtual colonoscopy study: a potential pitfall in \ndiagnosis. Case Report Med 2009; 2009: 379578. \n16. Teke Z, Aytekin FO, Atalay AO, et al. Crohn's disease complicated by \nmultiple stenoses and internal fistulas clinically mimicking small bowel \nendometriosis. World J Gastroenterol 2008; 14: 146-51.","source_license":"CC0","license_restricted":false}