{"paper_id":"444ed3a2-40a9-45b6-90b9-066282abff0d","body_text":"Ganglionic endometriosis with primary focus on the \nrectum–a rare case report\nSubmit Manuscript | http://medcraveonline.com\nIntroduction\nEndometriosis is a clinical entity defined by the presence of \nfunctioning endometrial tissue at sites outside the uterus. 1,2 It mainly \naffects women at fertile age in about 6-10% and is usually located \non the peritoneal surface of the reproductive organs. Extrapelvic \ninvolvement like rectosigmoid junction, sigmoid colon and rectum is \nvery uncommon. Symptoms such as pelvic pain, infertility or both \nare described in 40-80% of patients. 2,3 Colorectal endometriosis can \nbe asymptomatic or produce non-specific symptoms such, pelvic pain \nexacerbated with menstruation, rectal bleeding, dyspareunia, pain \non defecation, constipation and bowel obstruction. 4 Circumferential \ninvolvement of the rectum is rare and should be differentially \ndiagnosed from inflammatory or malignant diseases.4,5\nWe report a very rare case of an obstructive rectal mass of \nendometriosis with ganglionic involvement.\nCase report\nWe report a case of a 41-year-old woman with an history of \nchronic anemia and dysmenorrhea which was submitted to total \nabdominal hysterectomy and left-sided annexectomy right ovary \npreservation. During the procedure, a stenosing lesion of the \nrectosigmoid transition was observed. No approach to that lesion \nwas taken because further examinations were required. After clinical \nhistory, it was found an history of constipation over the last weeks \nand an abundant rectal bleeding without hemodynamic compromise, \ncolic abdominal pain and some abdominal distension mainly during \nmenstruation. As pathological antecedents, we mention Otto’s disease \n(it contraindicates hormone therapy), congenital hip dysplasia and two \ntransient ischemic vascular accidents. She was taking clopidogrel and \naspirin and has no family antecedents. Some studies were performed. \nComplete blood tests and tumor markers were normal. A total \ncolonoscopy was performed which identified a stenotic narrowing \n(15.8mm non-franchise at the 12.8mm colonoscope) at 15cm from \nthe anal margin, where the mucosa presented a discreetly infiltrative \n/ spongy appearance but with no inflammatory features. The suspicion \nwas endometriosis. Biopsies of the lesion were performed but the \nhistology was inconclusive only identifying inflammatory infiltrate, \nedema, and epithelial aspects of the regenerative, peudopolipoid \ntype. It was not found any criteria for morphological or pathological \ndiagnosis. Six months later, she repeated the colonoscopy in which \nit was identified an insurmountable stenosing lesion whose mucosa \nappeared normal. Newer biopsies were also inconclusive. She made a \ncomplete body tomography reporting a thickening in the rectosigmoid \ntransition without adenopathies or other relevant findings. Two months \nlater she undergone to a segmental resection of the rectum with total \nmesorectum excision without intercurrences. She was discharged on \nthe 6th postoperative day without pain and normal bowel function was \nmaintained without blood losses. The histological diagnosis confirmed \nthe endometriosis of the rectum with involvement of 23 lymph nodes. \nAt present moment, the patient is well without any complaint and has \ngynecological follow-ups.\nDiscussion\nEndometriosis was first described as the presence of functioning \nendometrial glands and stroma outsider the uterine cavity. As \nstated previously, women of reproductive age are affected in about \n6-10% complaining of pelvic pain and infertility in a large number \nof female patients. Bowel obstruction occurs in 10% of all cases \nof endometriosis. 6 colorectal obstructive endometriosis with colon \nor rectum involvement is rare. Over the years many theories have \nattempted to explain endometriosis pathogenesis such as Sampson´s \ntheory of retrograde spread, vascular dissemination, autoimmune \ndisease, colonic metaplasia among other. 7 Abros et cols suggest that \nendometrial tissue which grows around the rectum, and obstructs more \nthan 80% of lumen are more able to infiltrate the nearest ganglions. 8 \nSome authors point out two hypotheses to explain lymphatic affection \nsuch as metaplasia process of secondary Mullerian system and \nlymphatic drainage of endometrial tissue, defined at five different \nroutes.9,10 Intestinal endometriosis symptoms vary according to \nthe site of involvement. Abdominal pain, nausea, vomiting, fecal \ntenesmus, painful defecation, alternating constipation and diarrhea \ndistention and rectal bleeding. In our case, the patient complaint about \nMOJ Tumor Res . 2018;1(2):52‒53.\nVolume 1 Issue 2 - 2018\nMagda Alves, Catarina Caseiro, Nuno Bentes, \nPedro Correia\nDepartment of General Surgery, Hospital Vila Franca de Xira, \nPortugal\nCorrespondence: Magda Alves, Department of General \nSurgery, Hospital Vila Franca de Xira, Portugal, Email \nalves.magda0@gmail.com\nReceived: February 22, 2018 | Published: March 13, 2018\nAbstract\nEndometriosis is a pathology that is increasingly been diagnosed in women of \nreproductive age. It is located essentially in the pelvic region but may have an \nextrapelvic location. We describe a rare and exceptional case of an incidental \nintraoperative finding of a rectal stenotic mass, whose further study revealed an \nendometriosis focus with ganglionic extension to mesorectum.\n© 2018 Alves et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestricted use, distribution, and build upon your work non-commercially.\n52\nMOJ Tumor Research\nCase Report\n Open Access\n\n\nCitation: Alves M, Caseiro C, Bentes N, et al. Ganglionic endometriosis with primary focus on the rectum–a rare case report. MOJ Tumor Res. 2018;1(2):52–53. \nDOI: 10.15406/mojtr.2018.01.00011\nGanglionic endometriosis with primary focus on the rectum–a rare case report\nCopyright:\n©2018 Alves et al.\n53\nbowel habits changing, rectal bleeding and abdominal pain which \nincreases during menstrual period. Gastrointestinal endometriosis (3-\n37% of an ectopic location) may affect the ileum, appendix, sigmoid \ncolon and rectum being more frequent in the rectosigmoid (50-90%) \ncolon. Intestinal endometriosis often presents as a sub-mucosal tumor \nor luminal stenosis, because it mainly involves the muscularis propria \nand subserosa or even mesentery. Preoperative diagnosis of colorectal \nobstructive endometriosis is often difficult because of lack of definitive \ndiagnostic, clinical and radiologic findings. The case described \nemphasizes the incidental finding during a hysterectomy of a lesion \nwhich the main concern was a malignant rectal lesion. After several \nradiological exams including biopsies, the diagnosis remains doubtful. \nAs we far know, patients with chronic symptoms is easier to make a \nconnection and the study should include computed tomography (CT) \nscans, magnetic resonance imaging (MRI), and positron emission \ntomography (PET) scan in order to avoid false positive diagnosis of \nmalignant tumors. MRI appear to be more sensitive technique for \ncolorectal endometriosis with a positive predictive value about 89%. \nEndoscopy is another tool used in the diagnosis specially for making \nbiopsies. However, even with mucosal involvement, a clear diagnosis \ncannot usually be provided, because most of the times only shows \nsome unspecific inflammatory infiltration, as reported in our patient´s \ncase. It can be justified because the histological bowel wall changes \ninvolving endometriosis are located between muscularis fibers, \nsubserosa, and serosa, but mucosa is almost always intact. From \nthe recent literature, laparoscopy diagnosis is now the gold standard \napproach to diagnosis and the histopathologic and immunochemistry \nstudy confirms it. Colorectal endometriosis treatment is usually \nconservative (hormone therapy) in order to relief the symptoms. \nTherefore obstruction, bleeding or no medical response requires \nsurgical procedures. Free surgical margins are an important step \nafter the surgical removal because it is difficult to differentiate or \nexclude malignancy. Of the available literature, very little is known \nabout the most appropriate diagnosis for the affected nodes, nor is \ntheir approach, consequences, clinical evolution or more adequate \ntreatment. Further studies are needed to better understand this issue.\nConclusion\nColorectal obstructive endometriosis is rare and ganglion \ninvolvement is so far much rare. We should be aware of the symptoms \nin females in reproductive age specially the ones which became worst \nduring the menstrual period. Imaging exams could help but most of the \ntime is inconclusive and cam mimic other pathologies. Laparoscopy \ndiagnosis is a gold tool and histopathology confirms the diagnosis \nafter tissue removal. Malignancy should always be excluded. The \nlymph node spread, its treatment, evolution and prognosis is still a \nlimited field that requires more studies for better understanding and \napproach.\nAcknowledgment\nNone.\nConflict of interest\nThe authors declare no conflict of interest.\nReferences\n1. Yildirim S, Nursal TZ, Tarim A, et al. Colonic obstrution due to rectal \nendometriosis: report case. Turk J Gastroenterol. 2005;16(1):48–51.\n2. katsikogiannis N, Tsaroucha AK, Dimakis K, et al. Rectal endometriosis \ncausing colonic obstruction and concurrent endometriosis of the appen-\ndix: a case report. Journal of Medical Case Reports. 2011;5:320.\n3. Giudice LC, Kao LC. Endometriosis. Lancet. 2004;364(9447):1789–\n1799.\n4. Andrade M, Pimenta M, Belezia B, et al. Rectal obstruction due to \nendometriosis. Tech Coloproctol. 2008;12:57–59.\n5. Thomassin I, Bazot M, Detchev R, et al. Symptoms before and after \nsurgical removal of colorectal endometriosis that are assessed by mag-\nnetic resonance imaging and rectal endoscopic sonography. Am J Obstet \nGynecol. 2004;190(5):1264–1271.\n6. Ono H, Honda S, Danjo Y , et al. Rectal obstruction due to endometrio-\nsis: A case report and review of the Japanese literature. Int J Surg Case \nRep. 2014;5(11):845–848.\n7. Rock JA, Markham SM. Pathogenesis of endometriosis. Lancet. \n1992;340:1264–1267.\n8. Kheir SM, Mann WJ, Wilkerson JA. Glandular inclusions in lymph \nnodes. The problem of extensive involvement and relationship to salpin-\ngitis. Am J surg Pathol. 1981;5(4):353–9.\n9. Sánchez IO, Martin BC, Garcia JS, et al. Afectacion ganglionar en \npaciente com endometriosis profunda rectovaginal. Revista Chilena de \nobstetrícia y ginecologia. 2009;74(5):303–306.\n10. Javert CT. Pathogenesis of endometriosis based upon endometrial ho-\nmeoplasia, direct extension, exfoliation and implantation, lymphatic and \nhematogenous metastasis (including five case reports of endometrial \ntissue in pelvic lymph nodes). Cancer. 1949;2(3):399–410.","source_license":"CC0","license_restricted":false}