{"paper_id":"0ed00772-aa93-4bf5-b5ec-a36b348a0123","body_text":"Ranaweera et al. BMC Res Notes  (2016) 9:239 \nDOI 10.1186/s13104-016-2029-z\nCASE REPORT\nTerminal ilial intussusception in an adult \ndue to endometriosis\nR. K. M. D. C. D. Ranaweera1, S. M. K. Gamage2*, D. H. B. Ubayawansa1 and M. M. J. Kumara1\nAbstract \nBackground: Intussusception is invagination of a proximal segment of bowel into the distal segment in telescopic \nmanner. Although intussusception is common among children, intussusception secondary to terminal ileal endome-\ntriosis in an adult is a very rare encounter. We present such a case of intussusception in a Sri Lankan female.\nCase presentation: A 43 year old Sri Lankan female presented to the surgical casualty unit with features of a \nsubacute intestinal obstruction. Her past surgical and medical histories were unremarkable. On examination she was \nhaemodynamically stable with distended abdomen and there was generalized tenderness. There was no guarding or \nrigidity. No masses were palpable. Bowel sounds were increased. Her urine was negative for Human Chorionic Gon-\nadotrophin hormone. Full blood count revealed an increased white blood cell count with predominant number of \nneutrophils. Plain abdominal X-ray film showed dilated small bowel loops with empty rectum and distal colon. Patient \nunderwent emergency exploratory laparotomy. An annular growth at terminal ileum was noted. Proximal bowel \nloops were distended. There was no free fluid in the abdomen. Ileo caecal tuberculosis was suspected and right hemi-\ncolectomy was performed. Uterus and bilateral ovaries appeared normal. Post surgical recovery was uneventful. The \npathologist has noted endometriosis of terminal ileum contributing to the stricture formation and intussusception at \nthe site. Following recovery patient was referred to a Gynaecologist for management of endometriosis.\nConclusion: Though terminal ileal endometriosis is a very rare cause of intussusception it is important to consider \nthe possibility of it, especially when a female patient of reproductive age presents with symptoms and signs of intesti-\nnal obstruction.\nKeywords: Adult, Intussusception, Endometriosis, Intestinal obstruction\n© 2016 Ranaweera et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License \n(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, \nprovided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, \nand indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/\npublicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.\nBackground\nIntussusception is invagination of a proximal segment of \nbowel into the distal segment in telescopic manner caus -\ning intestinal obstruction [ 1]. This condition is usually \nseen in children of 6  months to 2  years age group and \nis rare in adults [ 1, 2]. Endometriosis is the presence of \nnormal endometrial tissue outside the uterus. Although \nendometriosis is a common condition among females \nof reproductive age, intestinal endometriosis is rare [ 2]. \nThere are several reported cases of endometriosis of sig -\nmoid colon and rectum but cases of small bowel endo -\nmetriosis are less reported [ 3, 4]. Intussusception and \nobstruction due to endometriosis of small bowel is a very \nrare encounter [1– 3]. We present a case of endometriosis \nof terminal ileum causing terminal ileal intussusception \nand obstruction at the site. There are only two reported \ncases of terminal ileal endometriosis causing intussus -\nception of bowel. Therefore this case will be an important \naddition to the available very short list of relevant litera -\nture. Objective of reporting this case is to add another \nextremely rare case of clinical importance to literature, \nthereby bringing awareness of such rare presentations \nand possible misleading points.\nCase presentation\nA 43 year old, single and nulliparous female from south -\nern province of Sri Lanka, presented to the surgical casu -\nalty ward with generalized colicky abdominal pain and \nOpen Access\nBMC Research Notes\n*Correspondence:  sujanig@pdn.ac.lk \n2 Department of Anatomy, Faculty of Medicine, University of Peradeniya, \nPeradeniya, Sri Lanka\nFull list of author information is available at the end of the article\n\nPage 2 of 3Ranaweera et al. BMC Res Notes  (2016) 9:239 \nconstipation for 7 days duration. However she has passed \nflatus. She has had nausea and vomiting for 4 days dura -\ntion which had been exacerbated on the day of presenta -\ntion. Her usual menstrual periods had a cycle duration of \n35–42  days and moderate bleeding lasting for 6–7  days \nwith tolerable lower abdominal and back pain lasting \nfor 3 days from the onset of bleeding. Her last menstrual \nbleeding had occurred 3  weeks prior. Her past medi\n-\ncal and surgical histories were unremarkable. There was \nno family history of bowel carcinoma or inflammatory \nbowel pathologies.\nOn examination patient was afebrile and not pale. \nShe was moderately dehydrated and was in pain. Pulse \nrate was 130 beats per minute and blood pressure was \n100/70  mmHg. Abdomen was distended and there \nwas generalized tenderness. There was no guarding or \nrigidity. No masses were palpable. Bowel sounds were \nincreased.\nHer urine HCG (Human Chorionic Gonadotro\n-\nphin hormone) was negative. Full blood count revealed \nincreased white blood cell count of 14  ×  109/L (per \nlitre) with 80 % neutrophils. Plain abdominal X-ray film \nshowed dilated small bowel loops with empty rectum and \ndistal colon.\nA nasogastric tube was inserted and intravenous fluid \nresuscitation was begun. Exploratory laparotomy was \nplanned. Midline abdominal incision was made and \nperitoneal cavity was opened into. An annular growth \nat terminal ileum was noted. Proximal bowel loops \nwere distended. There was no free fluid in the abdomen. \nIleo caecal tuberculosis was suspected and right hemi\n-\ncolectomy was performed. Uterus and bilateral ovaries \nappeared normal.\nPost surgical recovery was uneventful. Patient was \nstarted on prophylactic antibiotics. Bowel sounds \nappeared on post operative day 1 and she passed flatus \nand faeces on post op day 2 and 3 respectively. Patient \nwas discharged from hospital 4  days following surgery \nand she had no complains on discharge.\nThe pathologists report explained that on macroscopic \nexamination the terminal ileum had been oedematous \nand enlarged with a diameter of 4  cm. A stricture had \nbeen identified in terminal ileum 2  cm away from cae\n-\ncum. An intussusception had been visualized at the site \nof stricture. Microscopic examination revealed endome\n-\ntriosis of terminal ileum contributing to the stricture for -\nmation and intussusception at the site.\nThe patient was referred to a Gynaecologist for man -\nagement of endometriosis.\nDiscussion\nSmall bowel obstruction is a common cause for surgi -\ncal casualty admissions. It accounts for over 20  % of all \nhospital admissions due to acute abdominal pain. Malig -\nnant growths, strangulated herniae and adhesions are the \ncommon causes for small bowel obstruction in adults [5]. \nEndometriosis is the presence of endometrial tissue out\n-\nside the uterus. Although endometriosis in pelvis, rectum \nand sigmoid colon are reported frequently small bowel \nendometriosis is rarely reported. Occurence of small \nbowel endometriosis is reported to be only 0.5  % even \namong diagnosed endometriosis patients. Only 0.15 % of \npatients with small bowel endometriosis develop small \nbowel obstruction [2].\nIntussusception is a common cause of bowel obstruc\n-\ntion in children. Over 95  % of all reported intussus -\nception cases have occured in children, whereas only \n1–5  % were reported in adults [5 ]. In children intus\n-\nsusception is usually idiopathic or secondary to viral \ninfections [6 ]. However in adults, intussusception is \nusually due to ‘leading point’ [5 , 8, 9]. Leading point \nusually is a lesion in the lumen of the bowel which \ninterferes with the peristalsis process. Following the \ninterference, bowel segment above the lesion becomes \nconstricted and segment below becomes relaxed. \nContinuous peristalsis leads to telescoping of the \nproximal segment (intussusceptum) of bowel into the \ndistal segment (intussuscepiens) resulting in an intus\n-\nsusception [5 ]. The most common ‘leading points’ in \nadults are known to be malignant or benign tumors \n[6]. Bowel tuberculosis is a common differential diag -\nnosis especially in the South Asian region, mislead -\ning the surgeons as in this case. In this case terminal \nileal stricture caused by the chronic endometriosis has \nacted as the leading point.\nComplications of intestinal endometriosis include \nintestinal obstruction, hemorrhagic ascites, perforation \nand intussusception. If not treated immediately intus\n-\nsusception due to endometriosis may lead to intesti -\nnal obstruction and gangrene due to impediment of \nvenous followed by arterial blood flow [7 ]. The typical \nsymptoms suggestive of endometriosis are infertility, \ndysmenorrhoea and dyspareunia. It is not possible con\n-\nclude about this patients fertility and sexual intercourse \nsince she is single. In addition, in spite of having longer \nmenstrual cycle duration, patient does not have consid\n-\nerable pain on menstruation. Therefore it is rather dif -\nficult to have prior diagnosis of intestinal endometriosis \nespecially in a case like this, as the patient has had no \nconsiderably suspicious features suggestive of endo\n-\nmetriosis in her menstrual and reproductive histories. \nHowever, it is important to consider the possibility of \nintestinal endometriosis, especially when a female of \nreproductive age presents with features of intestinal \nobstruction. This may be of immense value in arriving at \na tentative diagnosis.\n\nPage 3 of 3\nRanaweera et al. BMC Res Notes  (2016) 9:239 \n•  We accept pre-submission inquiries \n•  Our selector tool helps you to find the most relevant journal\n•  We provide round the clock customer support \n•  Convenient online submission\n•  Thorough peer review\n•  Inclusion in PubMed and all major indexing services \n•  Maximum visibility for your research\nSubmit your manuscript at\nwww.biomedcentral.com/submit\nSubmit your next manuscript to BioMed Central \nand we will help you at every step:\nConclusions\nThough terminal ileal endometriosis is a very rare cause \nof intussusception it is important to consider the possi -\nbility of it, especially when a female patient of reproduc -\ntive age presents with symptoms and signs of intestinal \nobstruction.\nAbbreviations\nmmHg: millimetres mercury; HCG: human chorionic gonadotrophin; /L: per \nlitre; cm: centimetres.\nAuthors’ contributions\nRKMDCDR is the surgical registrar involved in the active management and sur-\ngery of patient and was involved in drafting the manuscript. SMKG performed \nthe literature search and prepared the manuscript. DHBU is the surgical \nregistrar involved in patient management and surgery. MMJK is the supervisor \nand the Consultant surgeon in charge of the patient. All authors read and \napproved the final manuscript.\nAuthor details\n1 Professorial Surgical unit, Teaching Hospital Galle, Galle, Sri Lanka. 2 Depart-\nment of Anatomy, Faculty of Medicine, University of Peradeniya, Peradeniya, \nSri Lanka. \nAcknowledgements\nWe wish to thank the ward and surgical theatre staff for their immense \nsupport.\nCompeting interests\nThe authors declare that they have no competing interests.\nConsent to publish\nWritten consent was obtained from the patient for publication of this case \nreport and images. A copy of the written consent form is available for  review \nwith the Editor of this journal.\nAvailability of supporting data and material\nSupporting data and material which may reveal the patients identity will not \nbe shared. All other data and material are contained within the manuscript. \nHowever all supporting data and resource material are available with the \nauthors.\nEthics and consent to participate\nWritten informed consent was obtained from the patient for the participation \nof this case report and images.\nReceived: 18 September 2015   Accepted: 7 April 2016\nReferences\n 1. Mittermair RP , Prommegger R, Zelger BG, Bodner E. Intestinal invagina-\ntion due to endometriosis of the terminal ileum. Dtsch Med Wochenschr. \n1999;124(50):1522–4.\n 2. Martinbeau PW, Pratt JH, Gaffey TA. Small bowel obstruction secondary to \nendometriosis. Mayo Clin Proc. 1975;50:239–43.\n 3. Al-Qahtani HH, Alfalah H, Al-Salamah RA, Elshair AA. Sigmoid colon endo-\nmetriotic mass. A rare cause of complete large bowel obstruction. Saudi \nMed J. 2015;36(5):630–3.\n 4. Yilmaz B, Cukur S, Sahin R. A case of rectal bleeding caused by digestive \nendometriosis resembling colon cancer. Endoscopy. 2014;46(Suppl):1.\n 5. Khwaja SA, Zakaria R, Carneiro HA, Khwaja HA. Endometriosis: a rare \ncause of small bowel obstruction. BMJ Case Rep. 2012;13:2012.\n 6. Azar T, Berger DL. Adult Intussusception. Ann Surg. 1997;226:134–8.\n 7. Koutsourelakis I, Markakis H, Koulas S, Mparmpantonakis N, Perraki E, \nChristodoulou K. Ileocolic intussusception due to endometriosis. JSLS. \n2007;11(1):131–5.\n 8. Denève E, Maillet O, Blanc P , Fabre JM, Nocca D. Ileocecal intussusception \nsecondary to a cecal endometriosis. J Gynecol Obstet Biol Reprod (Paris). \n2008;37(8):796–8.\n 9. Maltz C, Sonoda T, Yantiss RK. Endometriosis causing ileocecal intussus-\nception. Gastrointest Endosc. 2008;67(2):352–3.","source_license":"CC0","license_restricted":false}