{"paper_id":"24ca89a9-239f-425a-9bc9-ffdca83dbcbb","body_text":"Obstetrics and \nGynaecology Cases - Reviews\nCase Report: Open Access\nClinMed\nInternational Library\nCitation: Senturk MB, Guraslan H, Babaoğlu B, Polat M (2015) Intestinal Obstruction \ndue to Endometriosis Involving Atypical Hyperplasia: A Case Report. Obstet Gynecol \nCases Rev 2:051\nReceived: June 26, 2015: Accepted: July 21, 2015: Published: July 24, 2015\nCopyright: © 2015 Senturk MB. This is an open-access article distributed under the terms \nof the Creative Commons Attribution License, which permits unrestricted use, distribution, \nand reproduction in any medium, provided the original author and source are credited.\nSenturk et al. Obstet Gynecol cases Rev 2015, 2:4\nISSN: 2377-9004\nIntestinal Obstruction due to Endometriosis Involving Atypical \nHyperplasia: A Case Report\nMehmet B. Senturk1*, Hakan Guraslan2, Bülent Babaoğlu2 and Mesut Polat1\n1Department of Obstetrics and Gynecology, Zeynep Kamil Gynecologic and Pediatric Training and Research Hospital, \nTurkey\n2Departments of Obstetrics and Gynecology, Bakirkoy Dr Sadi Konuk Teaching and Research Hospital, Turkey\n*Corresponding author: Mehmet B. Senturk, Department of Obstetrics and Gynecology, Zeynep Kamil Gynecologic \nand Pediatric Training and Research Hospital, Opr. Dr. Burhanettin Ustunel Cad. No:10, Uskudar, Istanbul 34668, \nTurkey, Tel: +905417737176, Fax: +90 216 391 06 90, E-mail: dr.baki77@gmail.com\nfor laparotomy and a colostomy was opened by resection from the \nrecto-sigmoid region. In both ovaries, endometrioma of 5cm were \nobserved, which had moved towards the Douglas pouch in the left  \novary and widespread endometriotic foci were observed over the \nbroad ligament attached to the Douglas pouch. A diagnosis of Grade \n4 endometriosis was made [9]. As advanced stage endometriosis \nwas determined in the patient, there was a history of endometrioma \nsurgery and she was being followed up for pain, a total abdominal \nhysterectomy and bilateral oopherectomy were applied at the same \nsession for definitive treatment. No problems were experienced \nin the postoperative period and the patient was discharged on the \n7th day. The mass was causing a serosal adhesion and extending \n3.5 x 3 x 3cm within the intestinal lumen at 25cm length and 10cm \nwidth. Microscopic images of the mass are shown in figures 1 and \n2. The intestine was seen with transmural lumen involvement, \nshowing frequent changes in the endometriotic tissue and atypical \nAbstract\nIntestinal endometriosis is not a rare entity. However, malignant \ntransformation and emergency clinical table such as intestinal \nobstruction due to endometriosis are rare. This is an important \ncondition because it requires a multidisciplinary approach and \ncareful pathologic intervention especially in mass lesions. The \ncase is here presented of a patient who underwent laparotomy in \nthe emergency surgery clinic because of intestinal obstruction. The \npathology analysis revealed atypical endometrial hyperplasia in the \nendometriotic foci of the recto-sigmoid colon.\nIntroduction\nApproximately 15%-37% of patients with endometriosis have \nintestinal involvement [1-3]. The majority of these are located in \nthe recto-sigmoid (65.7%) and sigmoid (17.4%) [4]. Particularly, if \na mass has formed in these regions or if intestinal mucosa has been \nreached, an emergency clinical table may be seen such as abdominal \npain, rectal bleeding, diarrhea and occasionally intussusception \nand ileus [5-7]. When the mass grows and the area of involvement \nintensifies, even though it is rare, precancerous or cancerous changes \nmay be seen [8].\nThe clinical case is here presented of a patient who underwent \nemergent laparotomy because of intestinal obstruction.\nCase\nA 39-year old gravida 3 patient who presented with complaints \nof nausea, vomiting and no discharge of faeces or gas for 2 days was \nadmitted to the emergency clinic with an initial diagnosis of ileus. The \npatient had previously been operated on for ovarian endometrioma \nat another clinic and was being followed up for pain associated \nwith endometriosis. On the tomography image, a mass, 3.5-4.5cm \nin diameter, was observed in the recto-sigmoid region obliterating \nthe lumen. In addition, proximal to this mass, the colon reached \na diameter of 8cm. The preoperative haemogram and full urine \ntest biochemistry values were examined. The patient was admitted \n         \nFigure 1: Appearances of the endometriotic tissue in the bowel \n\nSenturk et al. Obstet Gynecol cases Rev 2015, 2:4\n• Page 2 of 3 •ISSN: 2377-9004\nsalpingo-oopherectomy. In 3 of these patients, adenocarcinoma \ndeveloped; adenocarcinoma in situ in 1, atypical endometrial \nhyperplasia in 2, adenosarcoma in 1 and adenofibroma showing \nborderline malignancy in 1. It was reported that unopposed estrogen \nhad a potential effect on the development of precancerous or \ncancerous lesions in endometriotic foci and pathologists should take \nthis into account when examining endometriotic foci.\nEndometriosis may be accompanied by clear cell ovarian cancer at \na rate of 30-40% and high grade serous ovarian carcinoma at less than \n10% [24]. Endometriotic tissue adjacent or attached to endometriotic \ntissue of normal appearance may hold cytologically atypical or obvious \ncancer tissue. Good evidence showing the relationship between this \nendometriosis and cancer has also reported a molecular and genetic \nrelationship. The mutation causing loss of function of the ARID \n1A gene has been seen in foci as atypical and cancer tissue together \n[25,26]. In addition, the CTNNB1 gene mutation has been reported \nin tissue formed of clear cell carcinoma, endometriotic ovarian \ncarcinoma and atypical endometriosis together [27]. Furthermore, \nin atypical endometriosis tissue which is included in carcinoma \ntissue, endometrial receptor expression continues and HNF 1B gene \nexpression is reduced [27].\nSometimes difficulties may be encountered in the differential \ndiagnosis of neoplasm occurring in the endometrial tissue from \nneoplasm originating in the epithelium or gastrointestinal normal \nmucosa. This differentiation is even more difficult in masses which \nhave extended into the lumen, therefore awareness of these types \nof lesions and careful examination by pathologists is important. \nMasses which are under the endometriosis support endometriotic \nadenocarcinoma, while atrophic gland and stroma may develop due \nto excessive growth of the lesion and neoplastic tissue may be seen [8]. \nThe location of the neoplastic tissue may be helpful in the differential \ndiagnosis. Primary colonic cancer always involves the mucosa. When \nthere are coexisting adenomatous changes in the mucosa, and are \noften associated with adenomatous changes or a neoplastic polyp in \nthe adjacent epithelium [8].\nPreneoplastic or neoplastic changes with intestinal pathologies of \nendometriosis are extremely rare. Apart from the ovary, the area of \nmost involvement is the colon and therefore symptoms often mimic \ncolon diseases. Thus, a multidisciplinary approach with general \nsurgeons is required for clinicians for the diagnosis and treatment of \ncolonic endometriosis. In addition, careful microscopic examination \nmust be made of the resected material, particularly in cases with a \nlarge or widespread mass.\nReferences\n1. Croom RD 3rd, Donovan ML, Schwesinger WH (1984) Intestinal \nendometriosis. Am J Surg 148: 660-667.\n2. Prystowsky JB, Stryker SJ, Ujiki GT, Poticha SM (1988) Gastrointestinal \nendometriosis. Incidence and indications for resection. Arch Surg 123: 855-858.\n3. Sapmson JA (1992) Intestinal adenomas of endometrial type: their importance \nand their relation to ovarian hematomas of endometrial type (perforating \nhemorrhagic cysts of the ovary. Arch Surg 5: 217-280 \n4. Chapron C, Chopin N, Borghese B, Foulot H, Dousset B, et al. (2006) \nDeeply infiltrating endometriosis: pathogenetic implications of the anatomical \ndistribution. Hum Reprod 21: 1839-1845.\n5. Yantiss RK, Clement PB, Young RH (2001) Endometriosis of the intestinal \ntract: a study of 44 cases of a disease that may cause diverse challenges in \nclinical and pathologic evaluation. Am J Surg Pathol 25: 445-454.\n6. Busard MP, van der Houwen LE, Bleeker MC, Pieters van den Bos IC, Cuesta \nMA, et al. (2012) Deep infiltrating endometriosis of the bowel: MR imaging as \na method to predict muscular invasion. Abdom Imaging 37: 549-557.\n7. Emmanuel R, Léa M, Claude P, Antonio V, Marianne Z, et al. (2012) Ileocolic \nintussusception due to a cecal endometriosis: case report and review of \nliterature. Diagn Pathol 7: 62.\n8. Yantiss RK, Clement PB, Young RH (2000) Neoplastic and pre-neoplastic \nchanges in gastrointestinal endometriosis: a study of 17 cases. Am J Surg \nPathol 24: 513-524.\n9. (1985) Revised American Fertility Society classification of endometriosis: \n1985. Fertil Steril 43: 351-352.\nhyperplasia in focal areas. On the posterior surface of the uterus, \nfocal endometriotic tissue was observed and findings were seen of \nendometrium delayed secretion. In accordance with the decision of \nthe general surgeon, the colostomy was closed after 2 weeks and end-\nto-end anastomosis was applied.\nDiscussion\nSince the first report of malignant transformation in ovarian \nendometriosis by Sampson [10], there have been several reports on \nthe malignant transformation of an endometriosis focal point [11-13]. \nThe majority of endometriosis cases involve serosal surfaces in the \ngastrointestinal system. As there are few studies in literature on the \nrelationship between the size of the mass in intestinal endometriosis \nand malignant transformation, there is a need for studies on this \nsubject [8,14-16].\nIn the majority of patients with these lesions, changes in intestinal \nhabits, rectal bleeding, abdominal cramps or vaginal bleeding may be \nseen [8]. However, the number of cases presenting with an emergency \nclinical table such as intussusception or intestinal obstruction is \nextremely low [5,7,8,17,18]. Aronchick et al. [14] reported the first \ncase of endometriosis who presented with ileocolic intussusception \nand bleeding. Then Deneve et al. [19] presented the case of a 43-\nyear old patient with non-reductable ileocolic intussusception and \nobstruction. In the majority of endometriosis showing subserosal \nlocation, especially when the muscle layer has started to be invaded, \ncolonic passage is slowed by impairment of colon peristalsis. Together \nwith transmural involvement, adhesion caused by significant \ninflammation may result in mural fibrosis with obstruction [5]. In \naddition, the mass formation caused by endometriosis may cause an \nobstruction in the lumen by extending in a polypoid way towards the \nlumen interior [5,14,15,20,21]. In the current case, the transmural \ninvolvement together with extension into the lumen had caused the \nobstruction. Yantiss et al. [8] reported a series of 17 patients including \n2 patients determined with endometrial hyperplasia. One of these \npatients presented with intestinal habit dysfunction and the other \nwith obstruction. Both patients were observed to have a 3.5cm mass \nand in the patient with obstruction, the mass in the sigmoid colon had \ndestroyed the mucosa, as in the current case.\nIt is well known that exogenous estrogen treatment can cause \nprecancerous or cancerous lesions in endometriotic tissue [22]. There \nhave been previous reports on the relationship between estrogen \ntreatment and precancerous or cancerous lesions in gastrointestinal \nendometriotic foci. Dunn et al. [23] presented a case of endometrioid \nadenocarcinoma in the ovarian endometriosis of a postmenopausal \npatient taking tamoxifen for breast cancer. In a report by Yantiss et al. \n[8], 8 of 17 cases had previously taken unopposed estrogen and had \npreviously undergone total abdominal hysterectomy and bilateral \n         \nFigure 2: Appearances of atypia\n\nSenturk et al. Obstet Gynecol cases Rev 2015, 2:4\n• Page 3 of 3 •ISSN: 2377-9004\n10. Sampson JA (1921) Perforating hemorrhagic cysts of the ovary: their \nimportance and especially their relationship to pelvic adenomas of \nendometrial type. Arch Surg 3: 245-323. \n11. Heaps JM, Nieberg RK, Berek JS (1990) Malignant neoplasms arising in \nendometriosis. Obstet Gynecol 75: 1023-1028.\n12. Mittal VK, Choudhury SP, Cortez JA (1981) Endometriosis of the appendix \npresenting as acute appendicitis. Am J Surg 142: 519-521.\n13. Scully RE, Richardson GS, Barlow JF (1966) The development of malignancy \nin endometriosis. Clin Obstet Gynecol 9: 384-411.\n14. LiVolsi VA, Perzin KH (1974) Endometriosis of the small intestine, producing \nintestinal obstruction or simulating neoplasm. Am J Dig Dis 19: 100-108.\n15. Sievert W, Sellin JH, Stringer CA (1989) Pelvic endometriosis simulating \ncolonic malignant neoplasm. Arch Intern Med 149: 935-938.\n16. Brooks JJ, Wheeler JE (1977) Malignancy arising in extragonadal \nendometriosis: a case report and summary of the world literature. Cancer \n40: 3065-3073.\n17. Le Meaux JP, Sangana G, Panel P, Raynal P (2007) [Digestive endometriosis \nof the caecum and intussusception: about one case]. Gynecol Obstet Fertil \n35: 1232-1234.\n18. Indraccolo U, Trevisan P, Gasparin P, Barbieri F (2010) Cecal endometriosis \nas a cause of ileocolic intussusception. JSLS 14: 140-142.\n19. Denève E, Maillet O, Blanc P, Fabre JM, Nocca D (2008) Ileocecal \nintussusception secondary to a cecal endometriosis. J Gynecol Obstet Biol \nReprod (Paris) 37: 796-798.\n20. Ozumba BC, Ojukwu JO, Anyaeze CM, Onuigbo WI (1993) Endometriosis of \nthe rectum. Br J Obstet Gynaecol 100: 963-964.\n21. Wynn TE (1971) Endometriosis of the sigmoid colon. Massive intramural \nhematoma. Arch Pathol 92: 24-27.\n22. Reimnitz C, Brand E, Nieberg RK, Hacker NF (1988) Malignancy arising in \nendometriosis associated with unopposed estrogen replacement. Obstet \nGynecol 71: 444-447.\n23. Duun S, Roed-Petersen K, Michelsen JW (1993) Endometrioid carcinoma \narising from endometriosis of the sigmoid colon during estrogenic treatment. \nActa Obstet Gynecol Scand 72: 676-678.\n24. Heidemann LN, Hartwell D, Heidemann CH, Jochumsen KM (2014) The \nrelation between endometriosis and ovarian cancer - a review. Acta Obstet \nGynecol Scand 93: 20-31.\n25. Wiegand KC, Shah SP, Al-Agha OM, Zhao Y, Tse K, et al. (2010) ARID1A \nmutations in endometriosis-associated ovarian carcinomas. N Engl J Med \n363: 1532-1543.\n26. Jones S, Wang TL, Shih IeM, Mao TL, Nakayama K, et al. (2010) Frequent \nmutations of chromatin remodeling gene ARID1A in ovarian clear cell \ncarcinoma. Science 330: 228-231.\n27. Anglesio MS, Bashashati A, Wang YK, Senz J, Ha G, et al. (2015) Multifocal \nendometriotic lesions associated with cancer are clonal and carry a high \nmutation burden. J Pathol 236: 201-209.","source_license":"CC0","license_restricted":false}