{"paper_id":"2d025159-fcb2-4876-8c33-7e12966c3555","body_text":"LETTER TO THE EDITOR\nLetter to the editor: recurrent symptoms of gastrointestinal tract\ncaused by isolated endometriosis in a middle-aged female\nChuan Zhang1 & Ye S u n1 & Dongsheng Zhang1 & Yueming Sun1\nAccepted: 26 January 2016 / Published online: 3 February 2016\n# The Author(s) 2016. This article is published with open access at Springerlink.com\nDear Editor:\nEndometriosis is defined as the presence of endometrial-like\ntissue outside the uterine cavity. Of all the cases of endome-\ntriosis, intestinal endometriosis accounting for about 10 %, the\nrectum and sigmoid colon are the most vulnerable position of\nthe intestinal tract.\nFor doctors, the diagnosis of colorectal endometriosis is diffi-\ncult, especially the differential diagnosis between this disease and\nother diseases such as malignancies, irritable bowel syndrome,\ninflammatory bowel disease, ileal Crohn’s disease, and so on,\ndue to its unspecific symptoms. Today, a large number of these\ncases are found accidentally at surgery and confirmed by pathol-\nogy. Here, we describe a case which has not a definite preoper-\native diagnosis, but the histopathological examination of the\nresected specimen showed ileocecal endometriosis infiltrating\nthe external muscular layer and two of the nine lymph nodes.\nClinical information\nA 47-year-old woman was referred to our hospital because of\ndyschezia, abdominal pain, abdominal distension, and mild\nnausea, associated with constipation. During 5 years before\nadmission, the patient had episodes of abdominal pain espe-\ncially at the lower abdominal and around the navel without\nobvious inducement. Abdominal pain can be relieved after\ndefecation. Passing feces is tough for her and it occurs once\neach 2 to 3 days. The feces, shape is thinner than normal, with\nmucus on the surface, sometimes with few blood.\nA colonoscopy performed in the patient\n’s hometown hospital\n4 months before admission, at about 11–16 cm from the anal\nmargin, revealed a stenosis with intact and a little thickened\nmucosa. Histopathological examination of the sigmoid from\nthe colonoscopy showed chronic inflammation of mucosa.\nTwo months earlier, the symptoms of dyschezia, abdominal\npain, and abdominal distension became worse and much more\nfrequent. However, the patient experienced no obvious im-\nprovement after antispasmodic and analgesic drugs were ad-\nministered in her hometown hospital. The patient got married\nat the age of 26 years and had one normal labor at the age of\n29 years, regular menses and no history of dyspareunia. Her\nlast menstrual period was 1 week before and it was unremark-\nable. She had no past history of hypertension, diabetes, coro-\nnary heart disease, tuberculosis, or other infectious diseases.\nBesides, she had no operation history, radiation exposure his-\ntory, or a poisonous chemical contact history. She also denied\nsmoking and has occasional alcohol use. Her father and moth-\ner were healthy without reporting previous history of such\ndisease. Her brother and her son were also healthy.\nThe abdomen looked flat with no intestinal type or peristal-\nsis wave. Palpation revealed mild lower abdominal tenderness\nand no abdominal masses or enlarged lymph nodes. The bow-\nel sounds were slightly increased. Rectal examination showed\nno blood or distinct mass. On the gynecological examination,\nher vulva, vagina, and cervix appeared to be normal. Her\nuterus had normal size and was anteverted.\nRoutine stool test was unnormal with occult blood active.\nRoutine blood test, coagulation parameters, contagious pa-\nrameters, routine urine test, liver function tests, renal function\ntests, AFP , CEA, CA199, and CA724 were all within normal\nrange, whereas CA125 was twice as much the normal level.\n* Yu e m i n g S un\njssunyueming@163.com\n1 Department of Colorectal Surgery, The First Affiliated Hospital of\nNanjing Medical University, 300 Guangzhou Road,\nNanjing, Jiangsu 210029, People’s Republic of China\nInt J Colorectal Dis (2016) 31:1511–1513\nDOI 10.1007/s00384-016-2522-9\n\n\nAn ultrasound colonoscopy underwent in our hospital after\nadmission showed an impassable stenosis, covered with\nrough, proliferous, anabrotic, and a little hematose mucous\nmembrane, 15 cm from the anus, and the scope could not pass\nthrough the lesion. The ultrasound scan revealed obviously\nthickened intestinal wall, low echo in wide range, and mucosa\nwith uncleared level. The pathobiology again confirmed mu-\ncosal chronic inflammation with lymphoid hyperplasia.\nA contrast-enhanced abdominal computed tomography\nscan revealed a swelling of the sigmoid wall and stenosis,\nand the uterine density was showed being not uniform.\nConcerning the duration, symptoms of incomplete intestinal\nobstruction, colonoscopy, and pathology reports, we thought\nthe possibility of inflammatory bowel disease was large and\ncould not completely rule out the possibility of tumor. In the\nlast 2 weeks, symptoms of dyschezia became more serious;\ndefecation was more difficult for her —it occurred once each\n3–5 days, and abdominal pain, abdominal distension, vomit,\nnausea were worse than before, accompanied by hemafecia.\nA laparoscopy performed 3 days later revealed obviously a\nsigmoid mass near the peritoneal fold, 4 × 3 cm in size; adhesion\nbetween the neck of the uterus and rectum; and adhesion be-\ntween the left ovary, fallopian tube, and the surroundings. No\nother organs were invaded. We resected the sigmoid at 12 cm\nabove the tumor and 4 cm below the mass accompanied by\nlymph nodes in groups 241, 242, and 251 by the standard of\ncarcinoma of the colon. Histopathological examination showed\nileocecal endometriosis affecting the external muscular layer and\ntwo of the nine lymph nodes. The postoperative course was\nuneventful; the patient recovered well and left the hospital 8 days\nlater. She was on regular follow-up and suffered no recurrence of\nthe same symptoms one and half years later.\nDiscussion\nEndometriosis is characterized as pelvic or extrapelvic, and\nthe gastrointestinal tract is the most common site of the\nextrapelvic implantation sites. Compared to ileum, appendix,\ntransverse colon, and cecum endometriosis usually arise in the\nrectosigmoid in 80 % of these cases.\nThe etiology of endometriosis is still elusive and among the\ntheories explaining the pathogenesis of endometriosis, the\nmost widely accepted theory is Sampson ’s Bretrograde\nmenstruation^ theory: endometrial tissue regresses through\nthe fallopian tubes, then implants and grows on the serosal\nsurface of extra-uterine organs.\nGastrointestinal tract endometriosis usually takes the form\nof asymptomatic small serosal implants. Influenced by hor-\nmone during menstruation, these implants may proliferate and\nbleed cyclically, bringing about non-specific symptoms like\nvomiting, diarrhea, constipation, pelvic pain, pencil-like stool,\ncyclical hematochezia, frequent urination, pain during defeca-\ntion, dyspareunia, infertility, and abdominal mass. Forty per-\ncent of the patients present symptoms in a cyclic manner,\nwhich are usually related with menses. In our patient, symp-\ntoms relapsed irregularly and were not related with menses.\nEndometriosis infiltrating the muscularis propria and after cy-\nclic proliferation, sloughing, and bleeding, inflammation and\nfibrosis appear and grow into the lumen, leading to obstruc-\ntion. Invasive bowel endometriosis can present as bowel ob-\nstruction in an acute, chronic, or intermittent manner. The true\nincidence of endometriosis causing bowel obstruction is un-\nknown, although complete obstruction of the bowel lumen\noccurs in less than 1 % of cases.\nBowel symptoms can present a confusing clinical picture\nand masquerade a wide spectrum of disease processes, includ-\ning irritable bowel syndrome, infectious disease, ischemic co-\nlitis, inflammatory bowel disease, ileocolonic intussusception,\nappendicitis, and malignancy.\nPhysical examination cannot often provide sufficient clues\nfor the diagnosis; hence, a timely and accurate preoperative\ndiagnosis is often delayed. Imaging studies, such as abdomi-\nnal CT, contrast-enhanced abdominal CT, magnetic resonance\nimaging (MRI), endoscopic ultrasound, and transvaginal so-\nnography, are widely applied for detecting alterations in the\nintestinal wall. Among these ones, MRI appears to be the most\nsensitive technique for colorectal endometriosis with a posi-\ntive predictive value of approximately 77.5–92.6 %. CT is not\nthe primary imaging modality for evaluation of bowel endo-\nmetriosis. Transvaginal ultrasound has a reported sensitivity\nof 91 % and specificity of 98 %. Endoscopy usually provide\nno valuable results for a definitive pathologic diagnosis be-\ncause of the intact mucosa due to the reason that endometriosis\ninvolves the deep layers of the bowel wall in general. But in\nour practical work, we still use endoscopy routinely for differ-\nential diagnosis, whether it is endometriosis or malignant le-\nsions or other diseases.\nAdditionally, most cases are found accidentally at surgery\nand the gold standard for the diagnosis is laparoscopy or lap-\narotomy, by which we can evaluate both the genital and intes-\ntinal tracts more completely and accurately.\nTreatment options comprise hormonal and surgical op-\ntions. But we should choose the appropriate method according\nto patient ’s age, fertility plan, the stage of the disease, and\ncomplications of the disease. Hormonal therapy can be con-\nsidered when the disease has no symptoms of obstruction and\nwe can apply hormones like danazol, gonadotrophin-releasing\nhormone (GnRH) analogs, and high-dose progestins. But\nthese medicines are not recommended for patients who desire\nto become pregnant.\nSurgery is the choice of treatment for intestinal endometri-\nosis when there are symptoms as intestinal obstruction,\n1512 Int J Colorectal Dis (2016) 31:1511–1513\n\nbleeding, severe pain, and if cancer cannot be excluded.\nNowadays, we use laparoscopy to resect the intestinal\nlesions completely to prevent the tumor growth more\noften than laparotomy unless there are complicated\nadhesions.\nOpen Access This article is distributed under the terms of the Creative\nCommons Attribution 4.0 International License (http://\ncreativecommons.org/licenses/by/4.0/), which permits unrestricted use,\ndistribution, and reproduction in any medium, provided you give appro-\npriate credit to the original author(s) and the source, provide a link to the\nCreative Commons license, and indicate if changes were made.\nInt J Colorectal Dis (2016) 31:1511–1513 1513","source_license":"CC0","license_restricted":false}