{"paper_id":"658a6f76-b0be-48c4-b390-0cc08f332dc7","body_text":"Endometriosis is the proliferation of endometrial glands in different parts of the\nperitoneum, causing inflammation, scars, infertility, and pain ( Donnez  et al ., 2002 ). The\ncondition affects 2-10% of women of reproductive age ( Giudice & Kao, 2004 ). Symptoms may vary from one individual to the\nnext, but they appear mostly during the menstrual period. They range from\ndysmenorrhea, chronic pelvic pain, infertility, and dyspareunia to bowel\ndisturbances. The rectum and the sigmoid colon are often involved, while the ileum\nis rarely compromised (4.1%) ( Tong  et\nal ., 2013 ). Most patients with endometriosis are diagnosed\nbetween the ages of 34 and 40 years ( Dimoulios\n et al ., 2003 ). The diagnosis of bowel endometriosis\nis not straightforward, since there is no specific sign to look for in preoperative\nexamination ( Dimoulios  et al .,\n2003 ). The patient featured in this case had deep endometriosis of the\nterminal ileum with perforation and peritonitis. Although most endometriosis-induced\nbowel perforations occur in the puerperal period, our patient was not pregnant.\n\nA 47-year old woman was admitted in our emergency department after suffering from\nsevere abdominal pain in the hypogastric and pelvic regions for two weeks. Her\ncondition worsened significantly three days prior to admission. She was vomiting and\nhad nausea and anorexia. Her last period had occurred three weeks prior to\nadmission. The patient was pale and feeling ill, but did not show signs of toxicity.\nHer heart rate was consistently at 110; her blood pressure was 100/70 mmHg; her oral\ntemperature was 38ºC; and her tilt test was negative. Her abdomen was soft,\nnon-distended, and she complained of mild tenderness to palpation. On auscultation,\nher bowel sounds were normal. Rectal and vaginal examinations were unremarkable.\nChest X rays and ECG were both normal. Baseline workup revealed a WBC of 9700, Hb of\n11, and a platelet count of 45300. Amylase, lipase, and aminotransferase readings\nwere normal and the patient had normal bowel movements. She reported a history of\ndysmenorrhea and dyspareunia started in her teen years. The rest of her medical\nhistory was unremarkable and she also had a normal pregnancy 14 years prior. CT\nscans from 10 days prior to admission showed the large loops of her small bowel were\ndilated down to the right side of the pelvic cavity. Colonoscopy, endoscopy, and\nupper gastrointestinal series with Gastrografin carried out a week before\nhospitalization were normal. Ultrasound examination showed an isoechoic hemorrhagic\nor endometrial cyst measuring 25×15mm in diameter consistent with a ruptured\novarian cyst, with mild to moderate amounts of fluid in the pelvis and abdomen. The\npatient was in observation for six hours and her condition deteriorated. Abdominal\ntenderness worsened, the patient became oliguric, and her Hb level dropped to\n9.6.\nThe tentative diagnosis was acute abdomen due to a ruptured cyst and persistent\nbleeding. She was sent to the operating room and had her abdomen opened with a\nmidline incision. Approximately two liters of bloody ascites were found, and a\nsample was sent for cytology testing. A perforation measuring 20mm in diameter was\nseen in the paramesenteric portion of the ileocecal part of the colon. The\nperforation was sealed with omentum and was surrounded with pus and fecal material.\nThe patient underwent a right hemicolectomy and a primary end-to-end\nanastomosis.\nHistopathology tests revealed the ascites fluid had blood cells and reactive\nmesothelial cells and no sign of malignancy. Samples of the terminal ileum, right\ncolon, and omentum revealed endometriosis with secondary ulceration, perforation,\nand inflammatory changes of the bowel wall ( Figure\n1 ). The omentum was unremarkable.\nFigure 1 Endometriosis with secondary ulceration, perforation, and inflammatory\nchanges of the bowel wall\nEndometriosis with secondary ulceration, perforation, and inflammatory\nchanges of the bowel wall\n\nEndometriosis affects 10-15% of women of reproductive age ( Tong  et al ., 2013 ). It is mostly a benign\ndisease, but in rare cases it may cause catastrophic complications needing prompt\nmedical attention. There are three kinds of endometriosis: superficial peritoneal,\novarian (endometrioma), and deeply infiltrating endometriosis.\nWhile the prevalence of endometriosis in asymptomatic patients is unknown, surgical\nstudies of women undergoing unrelated procedures have reported rates ranging between\n1 and 7 percent ( Sangi-Haghpeykar & Poindexter,\n1995 ). In women with history of endometriosis, rectovaginal or bowel\ninvolvement is seen in 5-25% of the cases ( Wills\n et al ., 2008 ). In one series the ileum was involved\nin 2-5% of the individuals with bowel or rectovaginal endometriosis ( Bailey  et al ., 1994 ). According\nto these authors, the most common symptoms seen in women with bowel endometriosis\nwere abdominal pain, rectal bleeding, palpable or radiographic mass, and\ndysmenorrhea ( Bailey  et al .,\n1994 ). Many women experience diarrhea, constipation, and bloating ( Yantiss  et al ., 2001 ). In rare\ncases, obstruction ( De Ceglie  et\nal ., 2008 ), ileus ( Bratu\n et al ., 2016 ), intussusceptions ( Ranaweera  et al ., 2016 ), and\npresumed rectal carcinoma ( Rana  et\nal ., 2016 ) may occur. Bowel endometriosis primarily affects\nthe serosa and muscle layers of the bowel ( Decker\n et al.,  2004 ), while transmural involvement into the\nmucosa is rare. Bowel perforation is an uncommon complication that generally occurs\nduring gestation ( Pisanu  et al .,\n2010 ). Rising progesterone levels that might decrease implant size can\ncause perforation in an already inflamed and weakened bowel ( Pisanu  et al ., 2010 ). Transvaginal ultrasound\nexamination may be helpful in diagnosing the condition (sensitivity 43.7%;\nspecificity 50%) ( Tong  et al .,\n2013 ). In most cases, it may determine whether the ovaries have been\ninvolved. MRI is currently one of the most accurate methods to diagnose bowel\nendometriosis (sensitivity 77-93%) (Tong  et al ., 2013).\nNonetheless, laparoscopy is still the gold standard ( Albareda  et al ., 2016 ).\nSurgery is the treatment of choice in complicated bowel endometriosis (obstruction,\nbleeding, and perforation). The choice of approach is based on surgeon experience\nand the extension, location, and degree of implant infiltration. Laparoscopy should\nbe attempted whenever possible ( Decker  et\nal ., 2004 ). Late diagnosis of all forms of endometriosis is\nstill an issue. Future studies should explore better ways to diagnose bowel\nendometriosis before the rise of complications.\n\nAlbeit rare, bowel perforations caused by endometriosis should be considered in the\ndifferential diagnosis of women of reproductive age with abdominal pain.","source_license":"CC0","license_restricted":false}