{"paper_id":"905ebbec-c14d-4861-b703-e3c9969dd4b6","body_text":"E960 CMAJ  |  AUGUST 17, 2020  |  VOLUME 192  |  ISSUE 33 © 2020 Joule Inc. or its licensors\nA\n36-year-old woman presented to the emergency depart-\nment with a 9-month history of abdominal pain accom-\npanied by rectal bleeding during menstruation. She was \notherwise well. Her pelvic and rectovaginal examination, as well \nas findings on transvaginal ultrasound,  were unremarkable. \nT2-weighted magnetic resonance imaging (MRI) showed a hypo -\nintense wall thickening in the sigmoid colon. We suspected endo-\nmetriosis and our differential diagnosis included inflammatory \nbowel disease and cancer. Colonoscopy showed a 30-mm submu-\ncosal lesion with a red, nodular surface in the sigmoid colon \n (Figure 1A). Pathologic examination of biopsy specimens was \nnonspecific. Subsequently, biopsies performed during a second \ncolonoscopy just before the patient’s menstrual phase showed an \nendometriotic gland and stroma, positive for estrogen receptor \n(Figure 1B). We diagnosed intestinal endometriosis. Our patient \npreferred to avoid long-term hormone therapy and accepted the \nrisk associated with laparoscopic sigmoidectomy. Laparoscopic \nexploration showed no other endometriotic implants.\nIntestinal endometriosis occurs in 5%–15% of women with \nendometriosis, and as was the case with our patient, about 20% of \nwomen with intestinal endometriosis do not have pelvic endo-\nmetriosis.1 The rectosigmoid colon is involved in 3 out of 4 patients \nwith intestinal endometriosis. Although MRI and transvaginal ultra-\nsound are sensitive diagnostic modalities for intestinal endometri-\nosis, definitive diagnosis requires a biopsy. Endoscopic biopsies \nfrequently yield insufficient tissue because the mucosal involve-\nment is sparse.2 We performed endoscopic biopsies just before the \nmenstrual phase, when endometriotic tissue is at its peak. First-line \ntreatment of endometriosis is hormonal, but surgery may be per-\nformed for severe intestinal stenosis or to accommodate a patient’s \npreference. The rate of recurrence after surgery is about 10%.3\nReferences\n1. Rossini LG, Ribeiro PA, Rodrigues FC, et al. Transrectal ultrasound — Techniques \nand outcomes in the management of intestinal endometriosis. Endosc Ultra-\nsound 2012;1:23-35.\n2. Bong JW, Yu CS, Lee JL, et al. Intestinal endometriosis: diagnostic ambiguities \nand surgical outcomes. World J Clin Cases 2019;7:441-51.\n3. Meuleman C, Tomassetti C, D’Hoore A, et al. Surgical treatment of deeply infiltrating \nendometriosis with colorectal involvement. Hum Reprod Update 2011;17:311-26.\nPRACTICE  |  CLINICAL IMAGES\nIntestinal endometriosis in a 36-year-old woman\nYasuhiko Hamada MD PhD, Kyosuke Tanaka MD PhD\nn Cite as: CMAJ 2020 August 17;192:E960. doi: 10.1503/cmaj.191471\nFigure 1: (A) Endoscopy image showing reddish nodules (arrows) atop a 30 mm submucosal lesion in the sigmoid colon of a 36-year-old woman. (B) Biopsy \nimage obtained just before the patient’s menstrual phase, showing a gland and stroma of endometrium (arrow) (hematoxylin and eosin stain; original \nmagnification x100.\nCompeting interests: None declared.\nThis article has been peer reviewed.\nThe authors have obtained patient consent.\nAffiliations: Departments of Gastroenterology and Hepatology \n(Hamada), and Endoscopic Medicine (Tanaka), Mie University Hospi-\ntal, Tsu, Japan \nCorrespondence to: Yasuhiko Hamada, \ny-hamada@clin.medic.mie-u.ac.jp","source_license":"public-domain-us","license_restricted":false}