{"paper_id":"55c26ffe-7de6-4d28-9f90-a512a7e91fa2","body_text":"Letters to the Editor\n1130-0108/2013/105/8/504-506\nRevista  e spañola  de  e nfeRmedades  d igestivas\nCopyRight  © 2013 a Rán  e diCiones , s. l.\nRev  e sp  e nfeRm  d ig  (Madrid\nVol. 105, N.º 8, pp. 504-506, 2013\nEnterovesical fistula and intestinal obstruction \nby ileal endometriosis\nKey words: Endometriosis. Ileum. Fistula. Intestinal obstruction. \nCrohn’ s disease.\nDear Editor, \nEndometriosis is one of the most common gynecological \ndiseases, is characterized by the presence of endometrial tissue \noutside the uterine cavity in women of reproductive age or per-\nimenopausal. Endometriosis “infiltrative in depth” is defined \nas one that penetrates more than 5 mm in the affected tissue, \noccurs in one third of all cases and is usually located in pelvic \nstructures. At ileum is very rare, 1-7 % of cases of intestinal \ninvolvement, with series and case reports in which the com -\nmon denominator is usually a result of intestinal obstruction \nin the same (1,2). Perforation is even stranger and we have not \nfound any published case that has caused enterovesical fistula \nas presented.\nCase report\nThis is a 45 years old patient diagnosed with Crohn’s disease \nwhen having episodes of abdominal pain, with terminal ileal \nstenosis objectified in a barium transit. Enter by pneumaturia \nand fecaluria, in CT scan highlights the dilatation of a segment \nof small intestine with stenotic area and bladder contrasted with \nthe image of a possible fistulous tract that seems to contact with \nthe area of stenosis of ileum (Fig. 1). At the intervention, short \nstenosis can be seen very close to the ileocecal valve without \nCrohn’s appearance, coupled with the bladder dome by the tract. \nIleocecal and indurated bladder wall segment resection was per-\nformed. Histology: Endometriosis in the mesenteric side of the \nileocecal valve and fibrinous inflammatory area corresponding to \nthe fistula, without histological lesions in ileal mucosa. Bladder \nwall with nonspecific mixed inflammation and giant cell reaction \n(Fig. 2). The postoperative progressing well and remains asymp-\ntomatic and untreated twelve months later.\nDiscussion\nEndometriotic foci, when implanted in the digestive tube \nwould produce, according to the novel “neurological hypothe -\nsis”, progressive infiltration into the muscularis propia and sub-\nmucosa along the nerve fibers (3). The mucosa is affected only \nrarely so the endoscopic study with biopsy is usually unspecific \nand this is one of the diagnostic difficulties. If we add that the \nsymptoms are not typical for gynecological endometriosis, the \nproblem of diagnosis is even greater (4).\nWhen affected terminal ileum, stenosis occurs suggesting \nCrohn’s disease, as in our case, being this the most important \naspect since both diseases have different treatments. There are \nnumerous reported cases of ileal endometriosis mimicking Crohn \nand eight cases where both diseases coexist (5). The multislice \nCT can make suspect this entity (2,6), but possibly the only thing \nconclusive is the exploratory laparoscopy and the diagnosis is \nstill given by the histological study (7).\nOur patient began with intestinal obstruction and enteroves -\nical fistula. There have been at least 14 reported cases of intes -\ntinal perforation by endometriosis and 3 fistulation but have not \nfound a case like the one presented (5,8,9). Why does this hap -\npen? It is noteworthy that in most of the few reported cases the \npatients were pregnant, were in the postpartum period, in oral \ncontraceptives or other hormonal therapy to cure the activity \nof endometriotic foci. This hormonal influence may produce an \ninitial decidualization and endometrial tissue growth, making it \nmore infiltrating in depth, coming to pass the mucous not only \nproducing stenosis but perforation or fistulation (3,8).\n\nV ol. 105, N.º 8, 2013 LETTERS TO THE EDITOR 505\nRev  esp enfeRm  Dig 2013; 105 (8): 504-506\nThe widely recommended treatment in all cases of intestinal \nendometriosis is surgical resection. When an implant is appreci-\nated by chance, might be consider performing a simple nodulec-\ntomy without bowel resection, but there are studies that show that \nit can be microscopically incomplete (10).\nIn conclusion, in front of a patient of childbearing age with \nabdominal pain or bowel obstruction, endometriosis with gastro-\nintestinal involvement should be considered in the differential \ndiagnosis, even without perimenstrual symptoms. It can simu -\nlate a stenosing or fistulizing Crohn’s disease. The diagnosis and \ntreatment will be surgical exploration with resection.\nJuan Antonio Asanza-Llorente1, Anastasio Serrano-Egea2, \nAntonio López-López1, Mónica García-Aparicio1, Teresa \nCalderón-Duque1 and Jesús Timón-Peralta1\n1Departement of General and Digestive Surgery. 2Department \nof Pathology. Hospital Nuestra Señora del Prado. Talavera de \nla Reina, Toledo. Spain\nReferences\n1. De Ceglie A, Bilardi C, Blanchi S, Picasso M, Di Muzio M, Trimarchi \nA, et al. Acute small bowel obstruction caused by endometriosis: A case \nreport and review of the literature. World J Gastroenterol 2008;14:3430-4.\n2. Fernández Rey CL, Álvarez González SA, Díaz Solís P, Blanco \nGonzález A, Costilla García S. Endometriosis ileal como causa de \nobstrucción de intestino delgado: diagnóstico por tomografía compu-\ntarizada multicorte. Rev Esp Enferm Dig 2009;12:872-4.\n3. Anaf V , El Nakadi I, Simon P, Van de Stadt J, Fayt I, Simonart T, el al. \nPreferential infiltration of large bowel endometriosis along the nerves \nof the colon. Hum Reprod 2004;19:996-1002.\n4. Yantiss RK, Clement PB, Young RH. Endometriosis of the intestinal \ntract: A study of 44 cases of a disease that may cause diverse challenges \nin clinical and pathologic evaluation. Am J Surg Pathol 2001;25:445-54.\n5. López PA, Martín L, Vicente M, Girón O, Del Pozo M. Ileal endo -\nmetriosis and Crohn´s disease. A difficult differential diagnosis. Cir \nEsp 2007;82:122-4.\n6. Biscaldi E, Ferrero S, Fulcheri E, Ragni N, Remorgida V , Rollandi GA. \nMultislice CT enteroclysis in the diagnosis of bowel endometriosis. \nEur Radiol 2007;17:211-9.\n7. Cameron IC, Rogers S, Collins MC, Reed MW. Intestinal endome -\ntriosis: Presentation, investigation and surgical management. Int J \nColorectal Dis 1995;10:83-6.\nFig. 1. CT scan which shows the large dilated loop of intestine longstanding stenosis (left) and contrast-filled bladder with fistula-ileum area (arrow).\nFig. 2. A. Histology showing endometrial tissue in the muscular enteric layer without affecting the mucosa (HE x10). B. Immunohistochemistry which \ndemonstrates the presence of endometrial tissue (CD10 x10).\n\n\n506 LETTERS TO THE EDITOR Rev  esp enfeRm  Dig (m aDRiD)\nRev  esp enfeRm  Dig 2013; 105 (8): 504-506\n8. Kalu E, Richardson R, Sellu D, Kubba F. Endometriosis-associated \nileo-cecal perforation in a woman on the pseudopregnancy regimen. J \nMinim Invasive Gynecol 2008;15:764-6.\n9. Sriganeshan V , Willis IH, Zarate LA, Howard L, Robinson MJ. Col-\nouterine fistula secondary to endometriosis with associated chorioam-\nnionitis. Obstet Gynecol 2006;107(2 Pt 2):451-3.\n10. Remorgida V , Ragni N, Ferrero S, Anserini P, Torelli P, Fulcheri E. \nHow complete is full thickness disc resection of bowel endometriotic \nlesions? A prospective surgical and histological study. Hum Reprod \n2005;20:2317-20.","source_license":"CC0","license_restricted":false}