{"paper_id":"1b5511cb-70ed-451c-93ca-aa976177387e","body_text":"A 43-year-old woman was evaluated for\nhematochezia. The patient reported\nmonthly episodes lasting 3 days, consist-\ning of lower abdominal cramping and\nsmall amounts of bright red blood with\nevery bowel movement. Her history was\nnotable for uterine myomectomy.\nColonoscopy revealed a nonbleeding, rub-\nbery, subepithelial mass in the rectum,\nmeasuring 1.5 × 1.5 cm, with a negative\npillow sign (\n●\" Fig. 1). Follow-up endo-\nscopic ultrasound (EUS) was serendipi-\ntously scheduled during her menstrual\nperiod and revealed patchy erythema on\nthe surface of the mass (\n●\" Fig. 2). The\nmuscularis propria appeared to be thick-\nened and contiguous with the uterus\n(\n●\" Fig. 3) leading to a diagnosis of rectal\nendometriosis. The patient was started\non oral contraceptives (OCPs) and leupro-\nlide, a gonadotrophin-releasing hormone\n(GnRH) analog, with complete resolution\nof rectal bleeding.\nIntestinal endometriosis is characterized\nby infiltration of the bowel wall by endo-\nmetrial-like glands. Pathogenesis is be-\nlieved to be secondary to retrograde pas-\nsage and implantation of endometrial tis-\nsue in the peritoneum. These implants,\nwhich are regulated by hormones, can in-\nfiltrate and proliferate through the bowel\nwall [1]. The most common locations are\nthe lower rectosigmoid colon, rectova-\nginal septum, and small intestine, with\napproximately a third of patients having\nmultiple areas of involvement [2]. Symp-\ntoms can range from asymptomatic\nlesions to frank rectal bleeding. Because\nthe intestinal mucosa is infrequently\ninvolved, cyclic bleeding is rare.\nUnless patients have hematochezia at the\ntime of evaluation, diagnosing intestinal\nendometriosis can be difficult. Colonosco-\npy is rarely helpful although other modal-\nities, including ultrasound (transvaginal\nor endoscopic), computed tomography,\nand magnetic resonance imaging, may\nassist in diagnosis [3]. Laparoscopy with\ndirect visualization and tissue sampling is\nconfirmatory. Medical management con-\nsists of hormonal therapy (OCPs, GnRH\nagonists, and synthetic androgens) and is\nthe standard approach for mild disease;\nsevere cases may require surgery [4].\nAlthough uncommon, intestinal endome-\nIntestinal endometriosis: an uncommon cause\nof rectal bleeding\nFig. 1 Colonoscopy\nshowing a rubbery, sub-\nepithelial rectal mass\nwith a negative pillow\nsign. The mass was\n1.5 × 1.5 cm in size.\nFig. 2 Endoscopy\ncarried out during\nmenstrual period\nshowing patchy muco-\nsal erythema.\nFig. 3 Endoscopic\nultrasound showing\nthickened muscularis\npropria apparently con-\ntiguous with the uterus\n(arrow).\nUCTN – Unusual cases and technical notesE112\nKwok RM et al. Intestinal endometriosis … Endoscopy 2010; 42: E112 – E113\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\ntriosis is an important consideration in\nfemales of reproductive age presenting\nwith rectal bleeding.\nEndoscopy_UCTN_Code_CCL_1AD_2AC\nR. M. Kwok, F. J. Moawad, J. T. Laczek,\nJ. D. Horwhat\nGastroenterology Service, Walter Reed\nArmy Medical Center, Washington DC, USA\nReferences\n1 Chapron C, Fauconnier A, Dubuisson JB et al.\nDeep infiltrating endometriosis: relation\nbetween severity of dysmenorrhoea and ex-\ntent of disease. Hum Reprod 2003; 18: 760 –\n766\n2 Macafee CH, Greer HL. Intestinal endome-\ntriosis. A report of 29 cases and a survey of\nthe literature. J Obstet Gynaecol Br Emp\n1960; 67: 539 – 555\n3 Remorgida V, Ferrero S, Fulcheri E et al. Bowel\nendometriosis: presentation, diagnosis, and\ntreatment. Obstet Gynecol Surv 2007; 62:\n461 – 470\n4 Olive DL, Pritts EA. Treatment of endome-\ntriosis. N Engl J Med 2001; 345: 266 – 275\nBibliography\nDOI 10.1055/s-0029-1243943\nEndoscopy 2010; 42: E112 – E113\n© Georg Thieme Verlag KG Stuttgart · New York ·\nISSN 0013-726X\nCorresponding author\nR. M. Kwok, MD\nDepartment of Medicine\nWalter Reed Army Medical Center\n6900 Georgia Avenue\nWashington DC 20307\nUSA\nFax: +1-202-782-4955\nRyan.Kwok@amedd.army.mil\nUCTN – Unusual cases and technical notes E113\nKwok RM et al. Intestinal endometriosis … Endoscopy 2010; 42: E112 – E113\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.","source_license":"CC0","license_restricted":false}