{"paper_id":"923da433-8027-4088-b8d4-b8eaabbb4dfe","body_text":"Sur Res J. (2023) Vol 3 Issue 1\nPage 1 of 3\nOriginal ArticleSurgery Research Journal\nISSN: 2768-0428\nCitation: Al-Mulla AE, Sultan AE, Al-Azemi B, Alansari MW, Alqattan KM. Sigmoid Colon Endometriosis \nCase Report: A Rare Large Bowel Entity. Sur Res J. 2023; 3(1):1-3.\nSigmoid Colon Endometriosis Case Report: A \nRare Large Bowel Entity\nAhmad Essam Al-Mulla1, Abdulla E Sultan1, Bashayer Al-Azemi2, Mohammad \nWaleed Alansari3, Khalid Mohammed Alqattan3\n1Consultant General and Bariatric Surgeon, Kuwait Board of General Surgery (KBGS), Fellowship Minimal Invasive and Bariatric \nand Endoscopy (Brazil), Fellowship American College of Surgeons (FACS), Department of Surgery Farwaniya Hospital, Ministry of \nHealth Kuwait (MOH), Farwaniya, Kuwait\n2Senior House Officer General Surgery (SHO), Department of Surgery, Farwaniya Hospital, Ministry of Health Kuwait (MOH), \nFarwaniya, Kuwait\n3General Surgeon trainee, Department of Surgery, Farwaniya Hospital, Ministry of Health Kuwait (MOH), Farwaniya, Kuwait\nCorrespondence\nAhmad Essam Al-Mulla MD, FACS \nConsultant General and Bariatric Surgeon. \nKuwait Board of General Surgery (KBGS), \nFellowship Minimal Invasive and Bariatric \nand Endoscopy (Brazil). Fellowship American \nCollege of Surgeons (FACS). Department \nof Surgery Farwaniya Hospital, Ministry \nof Health Kuwait (MOH), Sabah Al-Nasser, \nBlock 6, P . O. Box 13373, Farwaniya 81004, \nFarwaniya, Kuwait\nTel: 0096524888000\nE-mail: draalmulla2007@gmail.com\n•\t Received Date: 09 May 2023\n•\t Accepted Date: 15 May 2023\n•\t Publication Date:  22 May 2023\nKeywords\nEndometriosis, sigmoid tumour, endometrial \nmass, large bowel obstruction.\nCopyright\n© 2023 Authors. This is an open- access article \ndistributed under the terms of the Creative \nCommons Attribution 4.0 International \nlicense.\nIntroduction\nEndometriosis refers to ectopic uterine \nglands and stroma in the adnexa and pelvic \nregion [1]. The prevalence of endometrial \ntissue in reproductive females ranges from \n2–22%; however, this incidence is increased in \nfemales with dysmenorrhea and subfertility, \nranging from 40–60% and 20–40%, \nrespectively [2]. Large bowel masses caused \nby various aetiologies are among the most \ncommon presentations requiring surgical \nintervention. However, this presentation \nis rare in Endometriosis. This case report \ndescribes the course and management of a \n41-year-old female diagnosed with a sizeable \nendometriotic mass in the sigmoid colon.\nMethods\nA 41-year-old female was referred to \nour surgical casualty complaining of \nabdominal pain and rectal bleeding post-\ncolonoscopy. The patient had a history of \nchronic constipation and was referred to the \ngastroenterology team. A colonoscopy was \nperformed, which revealed a 7 cm sigmoid \nmass 28 cm from the anal verge. A biopsy \nwas taken; however, the procedure was \ncomplicated and aborted due to bleeding \nand a suspected bowel perforation. The on-\ncall surgical team were informed, and the \npatient was admitted to the surgical ward. \nThe patient was hemodynamically stable \nupon admission, with minimal tenderness \nin the left lower quadrant. All laboratory \ninvestigations appeared unremarkable. \nUrgent computed tomography (CT) scans \nwith intravenous and oral contrast were \nordered, which revealed a short sigmoid \ncolon segment with a nodular eccentric mass \nlesion and edge shouldering, measuring \napproximately 4 cm in length and 26 mm in \nwidth. The mass was observed to be causing \nluminal narrowing. However, there was no \nevidence of proximal significant colonic \ndilatation. The mass was associated with \nmild circumferential mural thickening of the \nadjacent sigmoid colon segments. There was \nno colonic perforation or contrast leakage \n(Figures 1 & 2). The patient was admitted to \nthe surgical ward for further observation. The \nhistopathology results from the colonoscopy \nrevealed morphological and immune-profile \nfindings of Endometriosis, with no epithelium \ndysplasia or malignancies identified. The \npatient was counselled regarding these \nfindings and was advised to undergo an \nelective laparoscopic left hemicolectomy. The \npatient consented to this procedure following \nanaesthesiology clearance. \nIntra-operative findings\nA sizable sigmoid mass was identified, \nand laparoscopic left-hemicolectomy was \nperformed using end-to-end anastomosis via \ncircular staplers. Drains were placed at the \nanastomosis site and pelvis.\nPost-operative findings\nThe patient tolerated the procedure well, \nwith no post-operative events. She was placed \non broad-spectrum antibiotics for five days \nand discharged after resuming a regular diet \nand demonstrating typical bowel motions. \nAbstract\nEndometriosis refers to the extrauterine presentation of ectopic functional uterine tissue. It is a common \ngynaecological condition in reproductive females. Its clinical presentation involves irregular menstrual \ncycles, pelvic pain, and infertility. However, it is highly unusual for Endometriosis to present as a large \nbowel mass with symptoms of obstruction. Here, we present a 41-year-old female with symptoms of \nchronic constipation and abdominal discomfort due to an endometrial colonic mass.\n\nPage 2 of 3\nAhmad Essam Al-Mulla, et al. Surgery Research Journal. 2023;3(1):1-3.\nSur Res J. (2023) Vol 3, Issue 1\nThe first outpatient clinic visit was 14 days after discharge. The \npatient reported no complaints, and the wounds were clean. \nHistopathology of the resected specimen revealed sigmoid \ncolon endometriosis with two doughnuts. In line with the \nprevious histopathology biopsy result, the margins were free, \nand 14 reactive lymph nodes were noted (Figures 3 & 4).\nDiscussion\nEndometriosis is defined as the implantation of \nendometrium outside the uterus. Endometriosis is thought \nto occur following retrograde menstruation [3] potentially. It \naffects approximately 10–20% of fertile females, with incidence \npeaking between the ages of 29–39 [4]. The gastrointestinal \ntract is involved in 3-37% of women with Endometriosis [5]; it \nwas first described in the 1950s [6]. There are several theories \nregarding how Endometriosis develops, including retrograde \nmenstruation and vascular dissemination. However, these \ntheories have little associated evidence. Endometriosis can \noccur in the entire abdominal cavity and can be categorized \ninto three groups: peritoneal, ovarian, and infiltrating \nEndometriosis [7]. Approximately 5–12% of females with \nEndometriosis develop infiltrating ectopic tissues in the recto-\nsigmoid leading to masses or narrowing. The mechanism \nbehind this is hypothesized to involve the response of smooth \nmuscle in the bowel to inflammation caused by ectopic \nendometrial stroma, leading to metaplasia, hyperplasia, and \nmuscle fibrosis, which consequently causes narrowing and \nobstruction [8]. \nThe diagnosis of intestinal Endometriosis can be challenging, \nas numerous differential diagnoses are associated with its \npresentation, such as neoplastic mass, lymphoma, diverticular \ndisease, and inflammatory bowel disease. Patients can present \nwith non-specific symptoms, such as constipation, diarrhoea, \ndysmenorrhea, pain during defecation, and intermittent \nrectal bleeding during menstruation [9]. Furthermore, \nphysical examination provides insufficient evidence to \nindicate a diagnosis. Transvaginal ultrasound is a highly \nreliable diagnostic tool, demonstrating a sensitivity of 91% \nand specificity of 96% [10]. Using the Doppler technique, \n \nFigure 1: Coronal view CT scan showing an infiltrating sigmoid endometrial mass. \nFigure 1. Coronal view CT scan showing an infiltrating sigmoid \nendometrial mass.\nFigure 2. Axial view CT-scan shows a nearly obstructing sigmoid \nendometrial mass.\nFigure 3. A gross examination of the sigmoid revealed a polypoid \nendometriotic lesion of size 3.0 x 2.5 x 2.5 cm on the opening of the \nsigmoid colon, having tiny haemorrhagic specks on the cut section.\nFigure 4. Microscopic images revealing endometrial glands and \nstroma among the sigmoid smooth muscle with high positive immuni-\nzation marker.\n\nPage 3 of 3\nAhmad Essam Al-Mulla, et al. Surgery Research Journal. 2023;3(1):1-3.\nSur Res J. (2023) Vol 3, Issue 1\ntransvaginal ultrasounds can detect reduced blood flow to the \nendometrioma. CT scans and magnetic resonance imaging \n(MRI) can reveal intestinal wall thickening and luminal \nnarrowing; however, for large infiltrating deep masses, MRI \nwith rectal contrast is the superior imaging technique [11]. \nEndometriosis management depends on its presentation \nand severity. For small deposits, medical management using \nnon-steroid anti-inflammatory drugs (NSAIDs) and oral \ncontraceptives is a viable option to reduce the deposit size and \nsy mptoms [12].\nNevertheless, larger masses with an obstructive presentation \nsimilar to our case report require surgical intervention. Several \ntechniques have been described for this purpose. However, \nlaparoscopic resection remains the gold standard except \nfor extensive adhesions requiring laparotomy with primary \nanastomosis [13]. Few complications associated with surgery \nwere mentioned in the literature, such as rectovaginal fistulae \nand anastomotic leakage, which have an incidence of 2-8% and \n3%, respectively [14]. The risk of recurrence after intervention \nfor infiltrating Endometriosis varies, and it is not easy to assess \nbecause of different studies and follow-ups duration. However, \nmost of the reviewers and authors conclude it is approximately \n5 -25% [1,15]; surprisingly, it is not influenced by the radicality \nof the resection [16].\nConclusion\nEndometriosis is a common presentation in reproductive-\nage women. Nevertheless, it is rarely presented as a colonic \nmass. This presentation can offer a formidable challenge to \nphysicians and surgeons; thus, it is essential to report such cases \nto help future doctors consider Endometriosis as a differential \ndiagnosis in women of productive age with gastrointestinal \nsymptoms.\nReferences\n1. Baden DN, van de Ven A, Verbeek PC. Endometriosis with \nan acute colon obstruction: a case report. J Med Case Rep. \n2015;9:150. \n2. Arafat S, Alsabek MB, Almousa F, Kubtan MA. A rare \nmanifestation of Endometriosis causing complete recto-sigmoid \nobstruction: A case report. Int J Surg Case Rep. 2016;26:30-33. \n3. Nassif J, Trompoukis P, Barata S, Furtado A, Gabriel B, Wattiez \nA. Management of deep Endometriosis. Reprod Biomed Online. \n2011;23(1):25-33. \n4. Bascombe NA, Naraynsingh V, Dan D, Harnanan D. Isolated \nendometriosis causing sigmoid colon obstruction: A case report. \nInt J Surg Case Rep. 2013;4(12):1073-1075. \n5. Insabato L, Pettinato G. Endometriosis of the bowel with lymph \nnode involvement. A report of three cases and a review of the \nliterature. Pathol Res Pract. 1996;192(9):957-962. \n6. Katsikogiannis N, Tsaroucha A, Dimakis K, Sivridis E, \nSimopoulos C. Rectal endometriosis causing colonic obstruction \nand concurrent Endometriosis of the appendix: a case report. J \nMed Case Rep. 2011;5:320. \n7. Meuleman C, Tomassetti C, D'Hoore A, et al. Surgical treatment \nof deeply infiltrating Endometriosis with colorectal involvement. \nHum Reprod Update. 2011;17(3):311-326. \n8. Nasim H, Sikafi D, Nasr A. Sigmoid endometriosis and a \ndiagnostic dilemma - A case report and literature review. Int J \nSurg Case Rep. 2011;2(7):181-184. \n9. Allan Z. A case of Endometriosis causing acute large bowel \nobstruction. Int J Surg Case Rep. 2018;42:247-249. \n10. Hudelist G, English J, Thomas AE, Tinelli A, Singer CF, \nKeckstein J. Diagnostic accuracy of transvaginal ultrasound \nfor non-invasive diagnosis of bowel endometriosis: systematic \nreview and meta-analysis. Ultrasound Obstet Gynecol. \n2011;37(3):257-263. \n11. Scardapane A, Lorusso F, Bettocchi S, et al. Deep pelvic \nEndometriosis: accuracy of pelvic MRI completed by MR \ncolonography. Radiol Med. 2013;118(2):323-338. \n12. Tarjanne S, Sjöberg J, Heikinheimo O. Rectovaginal \nendometriosis-characteristics of operative treatment and \nfactors predicting bowel resection. J Minim Invasive Gynecol. \n2009;16(3):302-306. \n13. Stepniewska A, Pomini P, Bruni F, et al. Laparoscopic treatment \nof bowel endometriosis in infertile women. Hum Reprod. \n2009;24(7):1619-1625. \n14. Koh CE, Juszczyk K, Cooper MJ, Solomon MJ. Management \nof deeply infiltrating Endometriosis involving the rectum. Dis \nColon Rectum. 2012;55(9):925-931. \n15. De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, \nKoninckx P. Bowel resection for deep Endometriosis: a \nsystematic review. BJOG. 2011;118(3):285-291. \n16. Mabrouk M, Spagnolo E, Raimondo D, et al. Segmental bowel \nresection for colorectal Endometriosis: Is there a correlation \nbetween histological pattern and clinical outcomes? Hum \nReprod. 2012;27(5):1314-1319.","source_license":"CC0","license_restricted":false}