{"paper_id":"8d10c783-692a-4423-a227-efad67d5381d","body_text":"333\nPerforation of the sigmoid colon secondary to endometriosis. \nCase report\nPerforación de colon sigmoides secundaria a endometriosis. Reporte de un caso\nErnesto A. Dzib-Calan 1*, Jorge I. Morales-Pérez 1, Juan C. Aranda-Puebla 2, Álex Simón-Mendoza 2, \nGerardo Rodarte-Cajica 2 and Gustavo Leal-Mérida 3\n1Postgraduate Naval School of Public Health; 2General Surgery Department; 3Surgical Areas. Hospital General Naval de Alta Especialidad, Mexico \nCity, Mexico\nCir Cir. 2018;86:333-335  \nContents available at PubMed  \nwww.cirugiaycirujanos.com\nAbstract\nBackground: Endometriosis is the presence of endometrial glands or viable stroma outside the uterine cavity, which affects \napproximately 2-10% of women of reproductive age 1. Pelvic structures, including the bowel, are commonly affected. Perfora -\ntion of the colon by endometriosis is very rare and represents a surgical emergency. Clinical case: A  28-year-old female \npatient with abdominal pain in the right iliac fossa and pelvic cavity, fever and nausea, exploratory laparotomy is performed \nwith the discovery of sigmoid perforation of the colon, requiring resection of the lesion and terminal colostomy, finding as \ndefinitive diagnosis endometriosis. Conclusion: Bowel or colon perforation is a rare but serious complication, which should \nalways be kept in mind as a suspicion of acute abdomen in a female patient of reproductive age and with a history of intermi -\nttent gastrointestinal symptoms.\nKEY\n WORDS: Endometriosis. Intestine. Colon. Perforation.\nResumen\nAntecedentes: La endometriosis es la presencia de glándulas endometriales o estroma viable fuera de la cavidad uterina, \nque afecta aproximadamente al 2-10% de las mujeres en edad reproductiva 1. Es común la afección de estructuras pélvicas, \nincluyendo el intestino. La perforación del colon por endometriosis es muy rara y representa una urgencia quirúrgica. \nCaso clínico: Mujer de 28 años con cuadro de dolor abdominal en fosa iliaca derecha y hueco pélvico, fiebre y náuseas. Se \nrealiza laparotomía exploradora con hallazgo de perforación de colon sigmoides, que requiere resección de la lesión y colos -\ntomía terminal, encontrando como diagnóstico definitivo endometriosis. Conclusión:  La perf\n oración de intestino o de colon \nes una complicación poco frecuente, pero de gravedad, que debemos tener siempre presente como sospecha ante un cuadro \nde abdomen agudo en una paciente en edad fértil y con antecedentes de haber presentado sintomatología gastrointestinal \nintermitente.\nPalab\nR\na\nS\n clav E:\n Endometriosis. Intestino. Colon. Perforación.\nCorrespondence: \n*Ernesto A. Dzib-Calan \nAv. Heroica Escuela Naval Militar, edif. 1, depto. 302 \nCol. Presidentes Ejidales 2da. secc. \nDel. Coyoacán, C.P. 04470, Ciudad de México, México \nE-mail: eangel_dc@hotmail.com\nDate of reception: 14-03-2018  \nDate of acceptance: 21-04-2018  \nDOI: 10.24875/CIRUE.M18000055\nCIRUGIA Y CIRUJANOS CLINICAL CASE\nNo part of this publication may be reproduced or photocopying without the prior written permission  of the publisher .   © Permanyer 2019\n\nCirugía y Cirujanos. 2018;86\n334\nIntroduction\nEndometriosis is the presence of endometrial glands \nor viable stroma outside the uterine cavity, which af -\nfects approximately 2-10% of women of childbearing \nage1. Involvement of pelvic structures, including the \nintestine is common.\nThe prevalence of intestinal endometriosis ranges \nfrom 5.3 to 12%. The rectum and the sigmoid colon \nare the most affected structures, with the ileum being \nmost rarely compromised\n2. Average age at diagnosis \nis 34-40\n y\nears3. Endometriosis-associated colon per -\nforation is very rare and patients generally are asymp -\ntomatic or have a painful pelvic mass in the left iliac \nfossa. The lack of pathognomonic signs and symp -\ntoms makes intestinal endometriosis a disease that is \ndifficult to suspect of and rarely preoperatively diag -\nnosed. Differential diagnoses include irritable  bowel \nsyndrome, infectious diseases, mesenteric ischemia, \nCrohn’s disease and neoplasm\n4.\nClinical case\nTwenty-eight-year-old woman with a surgical history \nof cesarean section 2\n y\nears prior for acute fetal dis -\ntress, last menstrual period (LMP) 15\n \ndays prior to \nadmission, and no chronic degenerative diseases, \nwho had attended the emergency department with a \n7-day history of abdominal colic-type pain localized at \nthe hypogastrium and right iliac fossa, with 7/10 inten -\nsity assessed with the analogue pain scale, without \nother accompanying symptoms, which was managed \non an outpatient basis with butylhyoscine, metam -\nizole, lysine clonixinate, cisapride, omeprazole and \nciprofloxacin, without improvement in 24 hours. She \nattended again with a 12-hour history of increased \npain, accompanied by nausea without vomiting, an -\norexia, non-quantified fever and pain reduction on \nleft-lateral position with legs flexed toward the abdo -\nmen/chest; she denied genitourinary or genital symp -\ntoms; last evacuation had been 16 hours prior, in small \namount and with normal characteristics.\nFindings on physical examination were: blood pressure \nat 110/60\n m\nmHg, heart rate 112 beats per minute, respi-\nratory rate 20 breaths per minute, temperature 38.2 °C, \nneurologically intact, no cardiopulmonary alterations, \nprotuberant abdomen due to subcutaneous fat, Pfannen-\nstiel-type scar, soft, depressible; positive McBurney, Von \nBlumberg, psoas, heel percussion and obturator signs; \nnegative Murphy, ureteral and pancreatic point and \nGiordano signs; intact extremities, and no neurovascular \ncompromise.\nBlood count: white blood cells 16.8 × 10\n3/L, neutro -\nphils 78.2%, hemoglobin 9.1\n \nmg/dL, platelets 589,000, \nnegative pregnancy test.\nExploratory laparotomy was performed due to the \nsuspicion of appendicitis, with the following findings: \ncecal appendix with normal characteristics, abscess \nin the sigmoid colon region of approximately 100\n \nmL, \nsigmoid colon with 10 × 10\n c\nm volume increase, with \nreddish-brown adipose tissue, with fibrinous exudate, \nand two 3.5 and 5-cm injuries breaking tissue conti -\nnuity on its cross-sectional surface ( Figs.\n \n1 and 2). \nSigmoidectomy was carried out, with distal stump \nHartmann pouch-type closure and end colostomy.\nPathology report: sigmoid colon serous and adipose \ntissue with presence of tubular endometrial glands with \nno atypia on their epithelium, surrounded by fusocel -\nlular endometrial stroma without atypia; endometrial \nglands epithelium positive for estrogen nuclear recep -\ntor and cytokeratin 7; endometrial stroma positive for \nFigure 1. Sigmoid colon perforation.\nFigure 2. Sigmoid colon segment.\nNo part of this publication may be reproduced or photocopying without the prior written permission  of the publisher .   © Permanyer 2019\n\nE.A. Dzib-Calan, et al.: Sigmoid colon perforation\n335\nCD 10; and vascular endothelium positive for CD 34, \nwhereby endometriosis foci were confirmed.\nDiscussion\nEndometriosis is a pathology that is considered to be \nbenign, but may have an aggressive behavior and \ncause serious complications. Intestinal endometriosis \nposes an important diagnostic challenge for surgeons, \ngynecologists and gastroenterologists in their practice.\nIntestinal serosa and muscle layers are commonly \naffected, while transmural participation in the mucosa \nis rare. Mucosal compromise constitutes the most \nsevere form of intestinal endometriosis. Most common \nlocalizations are the rectum and the sigmoid colon \n(73%), while involvement of the small intestine (2-\n16%), the appendix (3-18%), the cecum (2-5%) and \nthe ileum (4.1%) is exceptional\n2,5.\nSetubal and Sidiropoulou 6 reported three cases of \nendometriosis, all in pregnant patients, out of which \ntwo were known to have a history of endometriosis \nand one had no relevant history. In all of them, initial \nsymptoms were acute events of abdominal pain in the \npelvic region and required exploratory laparotomy. In \nall three cases, sigmoid colon involvement was found \nand resection of the compromised segment was car -\nried out.\nGalazis et al.\n5 reported the case of a non-pregnant \npatient presenting with a 1-month history bloating, nau -\nsea and vomiting, who referred sudden pain in the left \niliac fossa with irradiation to the suprapubic region, \nand a history of laparoscopy for endometriosis. She \nunderwent exploratory laparotomy, with sigmoid colon \nperforation being found, which prompted the perfor -\nmance of left hemicolectomy and end colostomy.\nGarg and Bagul\n7 reported the case of a female pa -\ntient with a 10-day history of colicky pain in the left \nflank and iliac fossa; she had suffered from endome -\ntriosis in the past. She underwent exploratory laparot -\nomy and an endometriotic mass was found in the left \novary and fallopian tube, with colon sigmoid \ninvolvement and perforation. Left hemicolectomy and \nproximal colostomy were performed, as well as endo -\nmetriotic mass and left annex resection.\nThe patient in our case, unlike most reported cases, \nhad no past history of endometriosis, which made \nsuspicion more difficult. Diagnosis can be difficult, \nsince most times there is no history suggestive of \nendometriosis, signs and symptoms are unspecific, \nand patients often present with acute abdomen, which \nrequires exploratory laparotomy.\nConclusion\nThis is a rare, but serious complication. Perforation \nmainly occurs associated with pregnancy, at its con -\nclusion and in the puerperium, and there are very few \nreported cases with no association with pregnancy. \nManagement should be multidisciplinary. This disease \nshould always be borne in mind as a suspicion in the \npresence of acute abdomen in a woman of childbear -\ning age and with a history of intermittent gastrointes -\ntinal symptoms. A\n \npast history of endometriosis or \ncoexistent gynecological symptoms should increase \nthe index of suspicion, and laparoscopy prior to formal \nlaparotomy should be considered if there is evidence \nof intestinal perforation.\nReferences\n 1 .  Cost a A, Sartini A. Deep endometriosis induced spontaneous colon \nrectal perforation in pregnancy: laparoscopy is advanced tool to confirm \ndiagnosis. Case Rep Obstet Gynecol. 2014;2014:907150.\n 2.\n  A\nlbareda J, Albi MV, Sosa G, Cano A, Macello ME, Albi Martin B. Puer -\nperal ileal perforation secondary to endometriosis: case report and lite -\nrature review. Taiwan J Obstet Gynecol. 2016;55:121-4.\n 3. Dim\noulios P, Koutroubakis IE, Tzardi M, Antoniou P, Matalliotakis IM, \nKouroumalis EA. A\n cas\ne of sigmoid endometriosis difficult to differentia -\nte from colon cancer. BMC Gastroenterol. 2003;3:18.\n 4. T\nong YL, Chen Y, Zhu SY. Ileocecal endometriosis and a diagnosis di -\nlemma: a case report and literature review. World J Gastroenterol. \n2013;\n19:3707e10.\n 5.\n  G\nalazis N, Arul D, Wilson J, Pisal N. Bowel endometriosis. BMJ Case \nRep. \n2014. pii: bcr2013202140. doi: 10.1136/bcr-2013-202140.\n 6. S\netubal A, Sidiropoulou Z. Bowel complications of deep endometriosis \nduring pregnancy or in vitro fertilization. Fertil Steril. 2014;101:442-6.\n 7. G\narg NK, Bagul NB. Intestinal endometriosis — a rare cause of colonic \nperforation. World J Gastroenterol.  2009;15:612-4.\nNo part of this publication may be reproduced or photocopying without the prior written permission  of the publisher .   © Permanyer 2019","source_license":"CC0","license_restricted":false}