{"paper_id":"4bf0057c-d06b-47a8-982f-83248113a04f","body_text":"Review began\n 07/26/2021 \nReview ended\n 08/01/2021 \nPublished\n 08/10/2021\n© Copyright \n2021\nShetty et al. This is an open access article\ndistributed under the terms of the\nCreative Commons Attribution License\nCC-BY 4.0., which permits unrestricted\nuse, distribution, and reproduction in any\nmedium, provided the original author and\nsource are credited.\nRare Case of Ileocecal Obstruction Secondary to\nEndometriosis Presenting for the First Time\nSushruth Shetty \n \n, \nDeepak Varma \n1.\n Surgical Gastroenterology, Mazumdar Shaw Cancer Centre, Bengaluru, IND \n2.\n Gastrointestinal Surgery, Health City\nCayman Islands, Grand Cayman, CYM\nCorresponding author: \nDeepak Varma, \ndeepak.varma@healthcity.ky\nAbstract\nThough endometriosis involving the intestines is well known, it causing ileocecal obstruction is a rare\npresentation. Etiology for ileocecal obstruction may not be known in all the cases preoperatively and may\nsometimes need resection and histopathology for diagnosis. Here we present a case of endometriosis\npresenting for the first time as an ileocecal obstruction in a 39-year-old lady who presented to us with\ncomplaints of intermittent abdominal pain. Contrast CT scan of the abdomen showed terminal ileal stricture\nand wall thickening. She underwent diagnostic laparoscopy, which showed dilated distal small bowel loops\nwith suspicious stricturing growth at the terminal ileum and ileocecal valve region. A formal laparoscopic\nright hemicolectomy was done and post-operative histopathology revealed endometriosis with fibrosis,\ncausing a luminal obstruction. In conclusion, endometriosis should be considered as a rare differential in\npatients presenting with ileocecal obstruction and having inconclusive features on imaging, endoscopic or\nbiopsy, especially in women of childbearing age.\nCategories:\n General Surgery\nKeywords:\n intestinal endometriosis, diagnostic laparoscopy, abdomen pain, right hemicolectomy, ileocecal\nobstruction\nIntroduction\nIntestinal obstruction at the ileocecal region is most commonly caused by aetiologies like tuberculosis,\nCrohn's disease, malignancy including lymphomas, radiation enteritis, or adhesions. Though endometriosis\ninvolving the intestines is known, these causing ileocecal obstruction is a rare presentation and is found\nonly as case reports \n[1-4]\n. Endometriosis is the presence of endometrial-type mucosa outside the uterine\ncavity. Menstrual irregularities, chronic pelvic pain, and urinary disturbances are the most frequently\nreported symptoms. Standard diagnosis is carried out by direct visualization and histological examination of\nlesions \n[5]\n. The most common site of extragenital endometriosis is the intestinal tract, and the reported\nincidence ranges from 3% to 37% in patients diagnosed with endometriosis \n[6,7]\n. Evaluation of a patient\nwith ileocecal obstruction is mainly by imaging and endoscopy with biopsy. But in many instances in\npatients with symptomatic obstruction, the final diagnosis is obtained only after surgical resection and\nhistopathological examination. Here we present a rare case of a patient with ileocecal obstruction who\nunderwent laparoscopic right hemicolectomy and post-operative histopathology revealed endometriosis.\nCase Presentation\nA 39-year-old lady presented to the ED with complaints of periumbilical abdominal pain and\nbilious vomiting. She had been experiencing similar symptoms intermittently for the past 6-8 months. Pain\naggravated after food intake. She had regular menstrual cycles and has one child born of normal term\ndelivery. She was evaluated elsewhere for the same and all her investigations were reported to be normal.\nShe had been managed conservatively for acid peptic disease. On examination she was in severe distress due\nto pain, hemodynamically stable, the abdomen was mildly distended but soft with some tenderness in the\nright iliac fossa and right lumbar area. A contrast CT scan of the abdomen was done which showed terminal\nileal stricture with wall thickening and significant proximal dilatation of ileum with positive small bowel\nfeces sign (Figure \n1\n). She was further evaluated by colonoscopy, which revealed that the ileocecal valve was\nedematous with hypertrophied Peyer's patches and with partial intussusception of terminal ileum into the\ncaecum. There was a significant narrowing of the distal-most ileum. Biopsies taken from the nodular areas\nof the mucosa showed only some nonspecific lymphoid tissue. All other tests done including tumor\nmarkers were negative. As even after 48 hours, she continued to have pain and abdominal distention, a\nrepeat CT scan was done which showed persistent dilated small bowel loops with terminal ileal obstruction.\nShe then underwent diagnostic laparoscopy which showed dilated distal small bowel loops with suspicious\nstricturing growth at the terminal ileum and ileocecal valve region (Figure \n2\n). In view of strong suspicion of\nmalignancy and nonavailability of frozen section examination, a formal laparoscopic right hemicolectomy\nwith stapled, side to side, ileo-transverse anastomosis was done. Postoperatively, she had an uneventful\nrecovery and was discharged home on postoperative day 4. On histopathology, gross examination showed\ncecal induration with intussusception of the distal terminal ileum into the cecum with associated\nobstruction of the ileocecal valve. Serial sections at the level of the cecum and distal terminal ileum showed\n1\n2\n \n Open Access Case\nReport\n \nDOI:\n 10.7759/cureus.17074\nHow to cite this article\nShetty S, Varma D (August 10, 2021) Rare Case of Ileocecal Obstruction Secondary to Endometriosis Presenting for the First Time. Cureus 13(8):\ne17074. \nDOI 10.7759/cureus.17074\n\nmarked fibrosis along the adjoining wall. The area of fibrosis extended partially along with the ileocecal\nvalve and partially along the cecal wall. On microscopy and immunohistochemistry, there were features\nsuggestive of endometriosis with PAX8 and estrogen receptors highlighting glandular epithelium nuclei and\nCD10 highlighting the surrounding stromal tissue.\nFIGURE\n 1: Thickening at the ileocecal valve and terminal ileum.\nArrow showing terminal ileum.\nFIGURE\n 2: Intraoperative picture of terminal ileal obstruction and dilated\nproximal bowel loop. Appendix was not visualized separately.\nDiscussion\nThe differential diagnosis for ileocecal obstruction may be varied but endometriosis is usually considered a\ncommon etiology, especially in patients without prior symptoms of endometriosis. The theory of retrograde\nmenstruation is the most commonly accepted hypothesis for endometriosis and rectosigmoid is the most\nfrequently involved segment of intestinal endometriosis \n[8,9]\n. The majority of the symptoms of\nendometriosis are cyclical, but this may not be true in all cases. Endometriosis mimicking Crohn's disease,\nirritable bowel syndrome, and even malignancies is known \n[5,6]\n. Deep infiltrating types of intestinal lesions\ncan cause complications and these usually warrant surgical resection \n[8]\n. Ileocecal involvement causing\nintestinal obstruction is very rare and pre-operative diagnosis may not be possible in all patients. The final\n2021 Shetty et al. Cureus 13(8): e17074. DOI 10.7759/cureus.17074\n2\n of \n3\n\ndiagnosis is based on histopathology and the presence of endometrial epithelial and stromal cells at ectopic\nsites. Studies also have proved the pro-fibrotic nature of these lesions which may be of the important\nmechanism by which it may cause intestinal obstruction \n[10]\n. This results in strictures which on imaging or\ndiagnostic laparoscopy may be difficult to differentiate from neoplastic lesions \n[2,7]\n. Medical management\nusually fails in these patients and hence almost always warrants resection \n[9]\n. Also in these patients, it is\nimportant to do a complete diagnostic laparoscopy to rule out other focuses of endometriosis, especially\nthose involving the intestines, as they are known to be multicentric and may cause complications if left\nbehind \n[2,11]\n.\nConclusions\nIntestinal obstruction secondary to endometriosis is rare and that too as the first presentation of\nendometriosis is very rare. It should be considered as a differential in patients presenting with ileocecal\nobstruction having inconclusive imaging, endoscopic and biopsy features, especially in women of\nchildbearing age group.\nAdditional Information\nDisclosures\nHuman subjects:\n Consent was obtained or waived by all participants in this study. \nConflicts of interest:\n In\ncompliance with the ICMJE uniform disclosure form, all authors declare the following: \nPayment/services\ninfo:\n All authors have declared that no financial support was received from any organization for the\nsubmitted work. \nFinancial relationships:\n All authors have declared that they have no financial\nrelationships at present or within the previous three years with any organizations that might have an\ninterest in the submitted work. \nOther relationships:\n All authors have declared that there are no other\nrelationships or activities that could appear to have influenced the submitted work.\nReferences\n1\n. \nKoyama R, Aiyama T, Yokoyama R, Nakano S: \nSmall bowel obstruction caused by ileal endometriosis with\nappendiceal and lymph node involvement treated with single-incision laparoscopic surgery: a case report\nand review of the literature\n. 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Hum Reprod. 2018, 33:347-352. \n10.1093/humrep/dex354\n11\n. \nHabib N, Centini G, Lazzeri L, Amoruso N, El Khoury L, Zupi E, Afors K: \nBowel endometriosis: current\nperspectives on diagnosis and treatment\n. Int J Women's Health. 2020, 12:35-47. \n10.2147/IJWH.S190326\n2021 Shetty et al. Cureus 13(8): e17074. DOI 10.7759/cureus.17074\n3\n of \n3","source_license":"CC0","license_restricted":false}