{"paper_id":"3dce71c5-bcdf-470f-8291-2771f6919b4f","body_text":"Content uploaded by Naya Alsouss\nAuthor content\nAll content in this area was uploaded by Naya Alsouss on Apr 27, 2026\nContent may be subject to copyright.\nTemplate ID: bluediamonds Size: 48x36\nUncommon Cause of Cyclical Bowel Symptoms: Recognizing Rectosigmoid Endometriosis in the\nSetting of Prior Cesarean Delivery\nNaya Alsouss (OMS-1)1, Austin Mahajan (OMS-2) 1, Suresh K. Mahajan MD 2\nOhio University - Heritage College of Osteopathic Medicine (OU-HCOM) 1, Southwest General Medical Center 2\nCase Overview\nA 34-year-old woman with a history of two cesarean deliveries initially presented with bright red blood\nper rectum and cyclical bowel habit changes characterized by constipation preceding menstruation\nfollowed by diarrhea after menses.\n•Initial colonoscopy was unrevealing\n•Symptoms were attributed to IBS and hemorrhoids\nThree years later, despite hemorrhoidectomy, the patient experienced persistent rectal bleeding with\nprogressive fatigue\n•Laboratory evaluation revealed recurrent anemia, Hb = 7.1 g/dL\n•Subsequent cross-sectional imaging demonstrated irregular thickening of the rectosigmoid junction\n•Repeat colonoscopy showed no mucosal abnormalities; however, there was a 2-cm intraluminal\nbulge with negative pillow sign (Figure 1). Mucosal biopsies were normal.\n•Endoscopic ultrasound identified a hypoechoic mass that appeared to arise from or invade into the\nmuscularis propria\nLaparoscopic partial left colectomy with concomitant peritoneal endometriosis ablation revealed florid\nendometriosis extending through much of the bowel wall, with involvement of through the muscularis\npropria (Figure 2)\n•Resection margins were free of disease, and pericolonic lymph nodes showed\nreactive hyperplasia\n•Following surgical intervention, hemoglobin and iron normalized\nReferences\nImages\nDiscussion\nKey Takeaways for Clinicians\nEndometriosis is a chronic estrogen-dependent inflammatory disorder that may involve extragenital organs, most\ncommonly the rectosigmoid colon. Intestinal involvement often presents with nonspecific gastrointestinal complaints.\nCesarean delivery as a risk factor for endometriosis: Women with prior cesarean delivery are 1.8x more likely to be\ndiagnosed with endometriosis later compared to women who deliver vaginally.1\nIatrogenic implantation theory: During cesarean delivery, endometrial cells can be mechanically implanted, or seeded,\ninto abdominal and pelvic tissue when the uterus is exposed\n•When endometrial cells are implanted into the surgical wound, they remain viable and proliferate under hormonal\nstimulation.2\nMenstrual-associated symptoms:\n•79% of patients with endometriosis experienced cyclic pain associated with menstruation.3\n•Endometrial implants undergo cyclical bleeding and inflammation, worsening symptoms during menses.3\nLimitations of endoscopy in detecting endometriosis:\n•Initial colonoscopy may be nondiagnostic: serosa or muscular layers affected – may not be visible during routine\nendoscopy\n•Diagnostic delay: symptoms can overlap with other gastrointestinal conditions4\n•Mean time from surgery to symptom onset: 3.7 years2\nThis represents a case of deep infiltrating rectosigmoid endometriosis with menstrual-related bowel symptoms and\nrecurrent anemia despite initial nondiagnostic colonoscopy. Repeat colonoscopy and imaging lead to the diagnosis.\nSurgical resection with peritoneal endometrioma ablation was curative.\n1. Andolf E, Thorsell M, Källén K. Caesarean section and risk for endometriosis: a prospective\ncohort study of Swedish registries. BJOG. 2013;120(9):1061-1065. doi:10.1111/1471\n0528.12236\n2. Nominato NS, Prates LFVS, Lauar I, Morais J, Maia L, Geber S. Caesarean section greatly\nincreases risk of scar endometriosis. European Journal of Obstetrics & Gynecology and\nReproductive Biology. 2010;152(1):83-85. doi:10.1016/j.ejogrb.2010.05.001\n3. Yıldırım D, Tatar C, Doğan O, et al. Post-cesarean scar endometriosis. tjod. 2018;15(1):33-\n38. doi:10.4274/tjod.90922\n4. Neamtu R, Dahma G, Mocanu AG, et al. Challenges in Diagnosis and Prevention of\nIatrogenic Endometriosis as a Long-Term Surgical Complication after C-Section. IJERPH.\n2022;19(5):2791. doi:10.3390/ijerph19052791\n•Prior cesarean delivery is associated with increased risk of endometriosis\n•Patients often present to PCPs with anemia and nonspecific GI symptoms\n•Endoscopy may fail to detect endometriosis because lesions are often in the\nouter layers of the bowel wall\n•In the setting of prior C-section delivery, PCP should have an increased index of\nthe suspicion for endometrial seeding after malignancy has been ruled out\nFigure 2: H&E stain demonstrating benign ectopic endometrial\nglands lined by simple columnar epithelium with surrounding\nendometrial stroma within the muscular wall of the sigmoid\ncolon.\nFigure 1: Colonoscopy revealing 2-cm intraluminal\nbulge at the rectosigmoid junction with no muscoal\nabnormalities.","source_license":"CC0","license_restricted":false}