{"paper_id":"5c397e36-44a2-4327-8cfc-56550711babb","body_text":"126126\nJournal of Digestive Endoscopy\nVol 5 | Issue 3 | July-September 2014\nIntroduction\nEndometriosis is defined as the appearance of endometrial \nglands and stroma outside the uterine cavity and musculature. \nAmong the extragenital site, intestinal endometriosis is most \ncommon. However, it is imperative to differentiate it from \nmalignancy, owing to similar endoscopic and radiologic \nfindings. We present a nulliparous married lady with a colonic \nendometriosis.\nCase Report\nThe 35‑year‑old female came to us with complaints of \nconstipation in form of  <3 bowel movements in a week \nfor last 3 years. Each bowel movement was associated with \nstraining, hard stools, feeling of incomplete evacuation and \npainful defecation. She noticed blood in stools which along \nwith constipation, which used to worsen prior to menstruation \nand relieved after menstruation. She took multiple laxatives \nfor constipation with partial relief. There was no history of \ndigital evacuation, weight gain or loss and other medication \nuse. There was no history of any co‑morbidity or surgery \nin the past. Her menarche was at the age of 14 years, and \nher cycle was regular at every 28–30 days, lasting 3–5 days. \nShe was married for the last 10 years. The patient was \nnulliparous and had an abortion 8  years back. Physical \nexamination and per rectal examination were unremarkable \nincluding anal sphincter tone. Laboratory parameters showed \nnormal investigations, including hemoglobin of 11.3  g/dl \n(normal 11.5–14.5 g/dl), serum calcium 9.5 mg/dl (normal \n8.5–11.5 g/dl) and thyroid stimulating hormone 2.3 U/dl \n(normal 0.5–4.5 U/dl). Colonoscopy was performed, which \nrevealed proliferative, near circumferential growth with \nsurface ulceration causing luminal narrowing in sigmoid \ncolon at 20 cm from anal verge [Figures 1 and 2] and rest \nof the colon till caecum was normal. Mucosal biopsies \nfrom the lesion showed chronic nonspecific inflammation \nwith no dysplasia. Magnetic resonance imaging (MRI) was \ndone, which showed near circumferential sigmoid colon wall \nthickening which was hyperintense on T1‑weighted (T1‑W) \nand T2‑weighted (T2‑W) sequence, which was continuous \nwith uterine wall but no lymphadenopathy or metastasis. \nEndoscopic ultrasonography [Figure 3] showed eccentric band \nof hypoechoic thickening of the muscularis propria measuring \n0.76 cm with a band extension of isoechogenicity into the \npericolonic area. The underlying mucosa and submucosa, \nincluding muscularis mucosa appear unremarkable with no \nlymphadenopathy. In view of the cyclical nature of bleeding \nwith constipation and other inconclusive investigations, \nlaparoscopy was performed to confirm endometriosis. \nLaparoscopy [Figure 4] revealed endometrial deposits showing \nburnt powder appearance on the urinary bladder, lateral \npelvic wall and anterior sigmoid colon and rectal wall with \nbilateral chocolate cyst appearance of ovaries and multiple \nadhesions between rectum, fallopian tube and uterus. Biopsies \ntaken were suggestive of fibroadipose tissue with lymphocyte \ninfiltration. She was diagnosed to have a sigmoid colon \nendometriosis causing luminal narrowing. She was started on \ngonadotropin‑releasing hormone after consultation regarding \nAccess this article online\nWebsite:\nwww.jdeonline.in\nQuick Response Code\nDOI:\n10.4103/0976-5042.147500\nCyclical constipation\nC. K. Adarsh, Keyur A. Sheth\nDepartment of Gastroenterology, St. John’s Medical College, Bengaluru, Karnataka, India\nAddress for correspondence:  \nDr. C. K. Adarsh, Department of Gastroenterology, St. John’s Medical College, Sarjapura Road, Bengaluru, Karnataka, India. E‑mail: adarshck@gmail.com\nAbstract Intestinal endometriosis is a rare disease. It can have a varied presentation. It is difficult to \ndifferentiate it from malignancy by clinical, endoscopic or imaging features. We present a \n35‑year‑old nulliparous married lady, who presented to us with constipation, painful defecation \nand bled per rectum for last 3 years. She was diagnosed to have endometriosis with gold \nstandard laparoscopy and managed with medical line of therapy.\nKey words Constipation, endometriosis, painful defecation, rectosigmoid\nCase Report\nPublished online: 2019-09-26\n\nAdarsh and Sheth: Cyclical constipation\n127127\nJournal of Digestive Endoscopy\nVol 5 | Issue 3 | July-September 2014\nfertility and were doing well for the last 3 months with medical \nline of treatment. Her bowel habits have normalized with no \nbleeding.\nDiscussion\nRokitansky[1] coined the term endometriosis in 1860, which is \ndefined as the appearance of endometrial glands and stroma \nother than uterine cavity or musculature. [2] It affects women \nof reproductive age group. It involves the intestine tract in \nabout 3–37% of patients affected with pelvic endometriosis.[3] \nRectosigmoid colon is most commonly affected part of the \nintestine, followed by appendix, distal ileum, and cecum. [4] \nIn a review of 379 patients with endometriosis, extragenital \nendometriosis constitutes of 8.9%. [5] In the same study, \nintestinal endometriosis constituted about 32.3% of extragenital \nendometriois.[5]\nThe clinical features of intestinal endometriosis are varied \ndepending on the structure or site of involvement. The \npresentation can range from asymptomatic to critical symptoms \nlike pelvic or lower back pain, constipation, diarrhea, cyclical \nrectal bleeding and rarely intestinal obstruction that may be \nassociated with menstruation. According to the structure of \ninvolvement, mucosal involvement presents as polypoidal \nbleeding mass, while muscularis propria or serosal involvement \npresents as submucosal tumor or luminal stenosis.[6] According \nto the site of involvement, rectosigmoid involvement causes \naltered bowel habits with bleeding, while colonic affection \ncauses perforation or peritonitis. [7] Small bowel involvement \ncan cause repeated abdominal pain with bloating while \ndistal ileum presents with acute or chronic obstruction. [7] On \nvaginal examination, painful pelvic nodularities and visible \nnodules in the posterior fornix are suggestive of the infiltrating \nrecto‑vaginal endometriosis. Chapron et al.,[8] showed severe \ndyspareunia and painful defecation, while Griffiths et al.,[9] \nshowed apareunia, nausea or abdominal bloating are \nassociated with the infiltrating recto‑vaginal endometriosis.\nThe manifestations of endometriosis need to be differentiated \nfrom malignancy, inflammatory bowel disease or ischemic \ncolitis. Hence, investigations are helpful for distinguishing \nFigure 1: Circumferential lumen narrowing lesion of endometriosis\n Figure 2: Ulcerated lumen narrowing lesion of endometriosis\nFigure 3: EUS showing eccentric band of hypoechoic thickening of \nthe muscularis propria\nFigure 4:  Laparoscopy showing endometrial deposits with burnt \npowder appearance\n\n\nAdarsh and Sheth: Cyclical constipation\n128128\nJournal of Digestive Endoscopy\nVol 5 | Issue 3 | July-September 2014\nendometriosis, but they are not diagnostic. Serum CA 125 \nmay help in the diagnosis of advanced stages of endometriosis, \nmore so when done early in menstrual period. [10] MRI of \nthe abdomen is best imaging technique with sensitivity and \nspecificity being 76% to 80% and 98% to 99%, respectively.[11] \nIt shows loss of fat‑tissue plane between colorectal wall and \nuterus with soft tissue mass extending along the colorectal \nwall showing hyperintense signals on T1‑W images and loss of \nhypointense signal of anterior bowel wall on T2‑W images.[11] \nThe modifications of sonography through transvaginal and \ntransrectal route have shown to be more accurate for diagnosis \nof colorectal endometriosis. Transrectal endoscopic ultrasound \nhelps in the evaluation of the submucosal lesion, recto‑vaginal \nseptum, and to determine layer of origin of the lesion with \nsensitivity and specificity being 97% and 96% respectively.[12]\nColonoscopy can be useful in excluding other gastrointestinal \npathologies and rarely evaluation of lesions that have mucosal \ninfiltration. In patients with endometriosis, colonoscopy \nshows eccentric wall thickening, polypoidal bleeding lesion \nand surface nodularity. In a study by Kim et al., consisting of \n17 patients most common location of colorectal endometriosis \nwas rectum (88%), followed by sigmoid colon (12%).[13] In the \nsame study, colonoscopy also showed eccentric wall thickening \nin 82% of patients, polypoid lesions in 18% of patients and \nsurface nodularity was found in 71% of patients.[13]\nIn spite of all the above investigations, laparoscopy still remains \nthe gold standard diagnostic procedure for endometriosis.[12] It \nnot only helps in identifying the extent and degree of lesions \nbut also obtains tissue for histological diagnosis. It shows \nclassical lesions like powder burn or gunshot lesions which \nare bluish, black or dark brown nodules or cyst containing old \nhemorrhage. The other nonclassical lesions include vesicles, \nplaques, scaring or adhesions. Laparoscopic intraoperative \nvisualization is diagnostic and histological biopsy is only \ncontributory if positive. [12] It can also be therapeutic at the \nsame situation.[12]\nIntestinal endometriosis being a rare presentation, there is a \nlack of consensus regarding the treatment. There are a number \nof factors to be considered before deciding for the treatment \nsuch as age, infertility, future pregnancies and intestinal \nsymptoms. The goals of therapy include symptom resolution, \nextraction of endometrial tissue, and stopping the disease \nprogression. The treatment of endometriosis includes medical \nor surgical intervention.[12] The medical therapies include oral \ncontraceptives, high‑dose progestins, gonadotropin releasing \nagonists (GnRH), and danazol. [12] Some studies have shown \nGnRH to be more efficacious then oral contraceptives.[12] The \npatients most suitable for medical therapy includes those not \nwanting pregnancy and who have undergone unsuccessful \nsurgical intervention.[12] The medical therapy is contraindicated \nin patients with symptomatic bowel stenosis, obstructive \nuropathy, doubtful etiology of an adnexal mass and those \nwho are desiring pregnancy. The indications for surgical \ninterventions include bowel obstruction, nonresponders, \nnoncompliance, and those not willing for medical therapy.[12]\nTo conclude, intestinal endometriosis is a rare entity. Due to \nlack of reliability of clinical features, endoscopic procedures \nand radiological studies, it is arduous to distinguish it from \nmalignancy. In the absence of tests for preoperative diagnosis \nand lack of consensus for therapy, it is imperative to consider \nintestinal endometriosis in women with reproductive age group \nwho are presenting with intestinal symptoms or intestinal mass \nof unidentified origin.\nReferences\n1. Bianchi A, Pulido L, Espín F , Hidalgo LA, Heredia A, Fantova MJ, et al. \nIntestinal endometriosis. Current status. Cir Esp 2007;81:170‑6.\n2. Olive DL, Schwartz LB. Endometriosis. N Engl J Med 1993;328:1759‑69.\n3. Croom RD 3rd, Donovan ML, Schwesinger WH. Intestinal endometriosis. \nAm J Surg 1984;148:660‑7.\n4. Zwas FR, Lyon DT. Endometriosis. An important condition in clinical \ngastroenterology. Dig Dis Sci 1991;36:353‑64.\n5. Douglas C, Rotimi O. Extragenital endometriosis – A clinicopathological \nreview of a Glasgow hospital experience with case illustrations. J Obstet \nGynaecol 2004;24:804‑8.\n6. Barclay RL, Simon JB, Vanner SJ, Hurlbut DJ, Jeffrey JF . Rectal passage \nof intestinal endometriosis. Dig Dis Sci 2001;46:1963‑7.\n7. Giudice LC, Kao LC. Endometriosis. Lancet 2004;364:1789‑99.\n8. Chapron C, Barakat H, Fritel X, Dubuisson JB, Bréart G, Fauconnier A. \nPresurgical diagnosis of posterior deep infiltrating endometriosis based \non a standardized questionnaire. Hum Reprod 2005;20:507‑13.\n9. Griffiths AN, Koutsouridou RN, Penketh RJ. Predicting the presence \nof rectovaginal endometriosis from the clinical history: A retrospective \nobservational study. J Obstet Gynaecol 2007;27:493‑5.\n10. Abrão MS, Podgaec S, Pinotti JA, de Oliveira RM. Tumor markers in \nendometriosis. Int J Gynaecol Obstet 1999;66:19‑22.\n11. Bazot  M, Darai  E, Hourani  R, Thomassin  I, Cortez  A, Uzan  S, et  al. \nDeep pelvic endometriosis: MR imaging for diagnosis and prediction \nof extension of disease. Radiology 2004;232:379‑89.\n12. Kennedy S, Bergqvist A, Chapron C, D’Hooghe T, Dunselman G, Greb R, \net al. ESHRE guideline for the diagnosis and treatment of endometriosis. \nHum Reprod 2005;20:2698‑704.\n13. Kim KJ, Jung SS, Y ang SK, Y oon SM, Y ang DH, Y e BD, et al. Colonoscopic \nfindings and histologic diagnostic yield of colorectal endometriosis. J Clin \nGastroenterol 2011;45:536‑41.\nHow to cite this article: Adarsh CK, Sheth KA. Cyclical constipation. J Dig \nEndosc 2014;5:126‑8.\nSource of Support: Nil, Conflict of Interest: None declared.","source_license":"CC0","license_restricted":false}