{"paper_id":"ae6ca60c-1d2b-4f49-97a7-fda799081892","body_text":"1\nIntestinal endometriosis as a cause of intestinal stenosis. \nA case report\nJosé M. Ruvalcaba-Vallarta*, Jesús A. Ruvalcaba-Velázquez, Shadid A. Rodríguez-Gómez, \nGerardo Bracamontes-Patiño, and Ma. Andrea Segovia-Cabañas\nGeneral Surgery Service, Hospital General Agustin O’Horan, Mérida, Yucatán, Mexico\nCLINICAL CASES\nAbstract\nEndometriosis affecting the terminal ileum is a rare condition, appearing in 1-7% of women with endometriosis, with second -\nary intestinal occlusion estimated in 7 -23%. Diagnosis before surgery is difficult and requires a high clinical suspicion; it \nshould be a differential diagnosis in all women with abdominal pain. The clinical case is a 26-year-old female presented with \nabdominal pain and a lack of bowel movements, with poor response to medical management. A computed tomography scan \nshows signs suggestive of intestinal obstruction, leading to surgical treatment. A diagnostic laparoscopy was initially planned; \nhowever, due to the unavailability of the necessary equipment, a laparotomy was performed. T wo areas of stenosis were found \nin the terminal ileum, managed with a right hemicolectomy and ileocolic anastomosis. Pathology reports revealed endome -\ntriotic implants in the areas of obstruction. In conclusion, while there is not established consensus regarding surgical man -\nagement, a minimally invasive approach is recommended when feasible.  Diagnosis can be confirmed only on \nhistopathological examination of the surgically resected specimen. The decrease in abdominal pain, gastrointestinal discom -\nfort, and the improvement in the quality of life are evident following surgical treatment.\nKeywords: Ileal endometriosis. Right hemicolectomy. Occlusion. Intestinal resection. Endometriosis. Stenosis.\n*Correspondence: \nJosé M. Ruvalcaba-Vallarta \nE-mail:  josruval79@gmail.com\nAvailable onl ine: 30-05-2025 \nRev Med Hosp Gen Mex. (Ahea d of print) \nwww.hospitalgeneral.mx\nDate or reception: 14-08-2024\nDate of acceptance: 21-10-2024\nDOI: 10.24875/HGMX.24000060\n0185-1063/© 2024 Sociedad Médica del Hospital General de Mexico. Published by Permanyer. This is an open access article under the  \nCC BY -NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).\nIntroduction\nEndometriosis is defined as the presence of endo -\nmetrium in an abnormal or ectopic location. Histologi -\ncally, it is the presence of endometrial-like tissue or \nglands outside the uterine cavity. It is a hormone-de -\npendent gynecological disorder that is most often seen \nin reproductively active women\n1,2.\nIt is a common cause of pain and infertility, but it also \nnegatively affects quality of life, intimate relationships, \nparticipation in daily activities, social activity, produc -\ntivity, and income\n2.\nIn their study, Fuldeore et al. report that the prevalence \nof diagnosed endometriosis was estimated at 6.1% (2,922 \nout of 48,020 women surveyed); 52.7% of women were \nbetween 18 and 29 years old when they were diagnosed \nwith endometriosis. The majority (86.2%) of women \nexperience symptoms before diagnosis3. In Mexico, the \nincidence of endometriosis in women with primary and \nsecondary infertility diagnoses has been studied, reach-\ning 34.5% in a sample of 197  patients; however, the \nnumber of fertile patients with endometriosis is unknown2.\nThe main theories about the pathogenesis of endo -\nmetriosis seek to explain the appearance of endometrial \ntissue outside the uterus. Among them are: the theory \nof retrograde menstruation, proposed by Sampson in \n1927, suggests that during menstruation, part of the \nRevista Médica del  \nHospital General de México\n\nRevista Médica del Hospital General de México. (Ahead of print)\n2\nflow moves through the fallopian tubes into the perito -\nneal cavity, carrying with it endometrial cells that adhere \nand proliferate in ectopic locations. Although it explains \nthe presence in the peritoneal cavity, it fails to justify \nother locations of the disease. Theory of coelomic \nmetaplasia: states that peritoneal mesothelium cells \ncan transform into endometrial tissue under specific \nhormonal or inflammatory stimuli. This could explain \nthe presence of endometriosis in more atypical sites, \nsuch as the diaphragm, where the phenomenon of ret -\nrograde menstruation would not have a direct role. \nTheory of lymphatic and blood dissemination: It pro -\nposes that endometrial cells migrate through the lym -\nphatic system and blood circulation, which would justify \nthe appearance of endometriosis in distant organs such \nas the lungs, brain, or even in the skin. Immunological \ntheory: Suggests that a dysfunction of the immune sys -\ntem prevents the recognition and elimination of endo -\nmetrial cells outside the uterus, allowing them to implant \nand grow. This would help to understand why some \nwomen with retrograde menstruation develop the dis -\nease, whereas others do not. Theory of genetic predis -\nposition and epigenetics: Recent studies indicate that \nthere are genetic and environmental factors that pre -\ndispose some women to develop endometriosis, alter -\ning the expression of certain genes and favoring the \nformation of lesions. Together, these theories indicate \nthat the pathogenesis of endometriosis is complex and \nmultifactorial, combining immunological, genetic, hor -\nmonal, and anatomical characteristics to different \ndegrees depending on each case 1,4-6.\nEndometriosis affecting the gastrointestinal tract \n(infiltrating deep endometriosis) has been reported in \nbetween 3% and 37% of menstruating women. It is \nseen in the rectum-sigmoid, cecum, small intestine, \nand appendix in decreasing order of frequency. Involve-\nment of the ileum is quite rare, and obstruction of the \nsmall intestine is very rare. Only a few cases have \nbeen reported so far, and all required emergency \nsurgery5,6.\nWe present the case of a patient with intestinal endo -\nmetriosis who presented with intestinal pseudocclusion \ndata, requiring emergency surgery. The diagnosis of \nendometriosis in the ileum was made by histopathology \nin the resected specimen.\nCase presentation\nThis is a 26-year-old female patient, with no medical \nor surgical history before admission, date of last \nperiod 2 weeks before, regular cycles of 28 × 4 days, \nactive sex life with barrier contraceptive method, dys -\nmenorrhea of more than 5 years of evolution, attended \nin the emergency department for the presence of \nabdominal pain of 2  weeks of evolution, intermittent \ntype, located in the right iliac fossa as well as in the \nhypogastrium, mild-to-moderate intensity, without irra -\ndiation to other areas and without apparent attenua -\ntion or aggravating factors, as the only accompanying \nsymptom he mentioned absence of bowel movements \n6 days before admission but with the presence of fla -\ntus, she self-medicated with oral analgesic having \npartial improvement, two similar previous conditions \nwhich were self-limiting.\nOn arrival at the emergency department, she had \nvital signs within normal parameters, physical examina -\ntion with flat abdomen, slight distension, peristalsis \npresent, decreased in frequency, pain on deep palpa -\ntion generalized without evidence of acute abdomen, \nrest without alterations. As part of the diagnostic \napproach, laboratory tests were requested with only an \nalteration in leukocytosis of 14.08 (×10 9/L) at the \nexpense of neutrophilia 79.5%. An abdominal X-ray in \ntwo positions and an abdominal ultrasound without \nreporting alterations.\nAs none of the studies were inconclusive and pain \nhad decreased, strict medical surveillance was decided \nwith bowel rest, defecatory surveillance, and analge -\nsics. 24 h later, she again presented abdominal pain, \nabsence of bowel movements, no fever, nausea or \nvomiting, demotion in leukocytosis and neutrophilia, for \nwhich a tomography of the abdomen and pelvis con -\ntrasted with the following findings: thickening of the ileal \nwall, maximum caliber of 44  mm, discrete striation of \nfat at the level of the terminal ileum at its junction with \nthe cecum in close relation to the apparent right annex, \nrest unaltered.\nIt was decided to perform diagnostic laparoscopy; \nhowever, the equipment was not available, so laparot -\nomy was performed, showing 12 areas of stenosis at \nthe level of the terminal ileum, the first at 8 cm from the \nileocecal junction, with an occlusion of 100% of its \nlumen when it rotated on its own axis, the second at \n15  cm from the ileocecal junction with occlusion of \napproximately 60% of its lumen ( Fig. 1 ). A right hemi -\ncolectomy was performed with mechanical ileotrans -\nverse anastomosis. The histopathological report of the \nspecimen sent was: endometriosis in the muscle wall \nand serous wall of the ileum (transmural involvement), \nas well as secondary extrinsic compression in two \nareas, surgical edges without histological evidence of \nlesion (Fig. 2 ).\n\nJ.M. Ruvalcaba-Vallarta et al.  Intestinal endometriosis as cause of stenosis\n3\nFigure 1. A: the area of stenosis in the terminal ileum (white circle), found as a finding during laparotomy, is \nappreciated. B: specimen resulting from right hemicolectomy with a stenosis area with torsion on its own axis (white \narrow). Source: authors’ own elaboration.\nThe patient evolved favorably, tolerating a liquid diet \nat 24 h postoperatively and a normal diet at 36 h. The \npatient was discharged on the 6 th day and summoned \nto an outpatient clinic for the removal of stitches, finding \na wound in adequate condition. 2  months later, with \ntotal remission of symptoms, she was discharged from \nthe General Surgery Service and sent to the Gynecol -\nogy Service due to histopathological diagnosis of \nendometriosis.\nDiscussion\nCountless hypotheses and theories have been pro -\nposed for the pathogenesis of endometriosis. From the \nimplantation theory, which is currently the most widely \naccepted, to the stem cell theory. However, it is cur -\nrently still a question to be resolved1,2,5,6. Endometriosis \ncan be asymptomatic, but it also presents a wide vari -\nety of clinical manifestations, including pain, dyspareu -\nnia, intermittent bleeding, and infertility. The symptoms \nthat have the greatest impact on the quality of life of \npatients are those associated with pain, such as dys -\nmenorrhea, profound dyspareunia, cyclic pelvic pain, \ndysuria, and dyschezia, which occur cyclically accord -\ning to the menstrual cycle. In addition, intestinal endo -\nmetriosis can cause irritative functional symptoms, \nsuch as diarrhea, intestinal cramps, hematochezia, and \nmucus expulsion, due to the cyclic release of inflam -\nmatory mediators, as well as obstructive mechanical \nsymptoms, such as constipation and abdominal disten -\nsion, caused by enlarged nodules, intestinal angulation \nand stenosis, and retraction of fibrotic tissue. Some \nspecific symptoms, such as cyclic dysphasia and \ntenesmus, are typical of rectal endometriosis 1,2,5-7.\nTo date, no individual classification system ade -\nquately classifies endometriosis. The American Society \nfor Reproductive Medicine’s revised criteria for staging \nendometriosis (revised American Society for Reproduc -\ntive Medicine) are the most widely used and are useful \nfor clinicians to explain the severity of endometriosis in \nsimple terms to patients. The ENZIAN classification \ndescribes in detail infiltrating deep endometriosis (PID) \ninvolving retroperitoneal and/or abdominal structures. \nBA\nFigure 2. A: photomicrograph shows ileum mucosa. \nBelow in the muscular mucosa, note the presence of \nglands and stroma with endometrial phenotype.  \nB: photomicrograph shows glands and endometrial \nstroma without atypia, immersed in smooth muscle of \nthe intestinal muscularis propria with transmural \ninvolvement.\nA B\n\nRevista Médica del Hospital General de México. (Ahead of print)\n4\nIn addition, the ENZIAN classification is probably most \nuseful when determined using imaging modalities and \ncan be used for surgical planning; however, it has little \nacceptance worldwide 1,8,9.\nPreviously, diagnostic imaging modalities were not \nvery successful, but new advances in the field of imag -\ning show promising results for detecting intestinal \nlesions. In a report, Gillen et al. show that multislice \ntomography combined with oral contrast located 94.8% \nof intestinal endometriotic nodules 10. Magnetic reso -\nnance imaging has a high sensitivity for detecting \nendometriosis, but it has difficulty distinguishing it from \nother diseases, as well as being expensive 10-12. Ultra -\nsound, on the other hand, is an inexpensive and effi -\ncient means of examining and diagnosing intestinal \nendometriosis. However, diagnostic accuracy depends \nsignificantly on the sonographer’s experience 1,13.\nDue to the low frequency and non-specific symptoms, \nmultiple differential diagnoses should be considered, \nsuch as tuberculous enteritis, yersinia enterocolitis, car -\ncinoid tumors, lymphomas, Behçet’s disease, and amoe-\nbomas, among others. The final diagnosis is based on \nhistopathology and the presence of endometrial epithe -\nlial and stromal cells at ectopic sites 2,5,6,11-13.\nThe quality of the available evidence on medical \ntreatment for intestinal endometriosis is suboptimal. \nMost studies were not comparative. There are very \nfew reported cases in which infiltrating deep intesti -\nnal endometriosis has been resolved by non-surgical \nmanagement when symptoms persist or worsen, \nand with the disadvantage that treatment cannot be \ninterrupted 14.\nMedical treatment should not be suggested if the \nlesion is located above the middle part of the rectum, \nthe degree of lumen stenosis is > 60%, if the lesion \ninfiltrates > 50% of the intestinal circumference, or if \nthe largest diameter of the nodule is > 3  cm, \nthe same rule is followed in the locations in the small \nintestine7,14-16.\nSurgical treatment depends on the degree of intesti -\nnal involvement and the clinical condition of the patient \nat the time of diagnosis. Ideally, it consists of intestinal \nresection of the affected ileal segment and primary \nanastomosis; however, cases have been reported in \nwhich right hemicolectomy is performed with or without \nanastomosis, preferring in either case the minimally \ninvasive approach. When there is doubt of malignancy, \nresection with oncological criteria is justified and should \nbe considered at the discretion of the surgeon 17-22.\nAlthough successful cases have been presented with \nmedical management, high recurrence rates continue to \nbe shown in contrast to patients who undergo resection, \nhave significant and persistent long-term improvement \nin pelvic pain, gastrointestinal discomfort, and quality of \nlife, as well as a negligible recurrence rate 14,23,24.\nPharmacological therapy plays a fundamental role as \na complement to surgical intervention, both in the \npre-operative period and, more significantly, in the \npost-operative phase. In the pre-surgical context, its \nuse can contribute to the reduction of the size of the \nlesions, thus facilitating the intervention. Subsequently, \nin the post-operative period, pharmacological therapy \nis essential to reduce the size of residual implants, \ncontrol the progression of the disease in cases where \nsurgical resection has not been able to be carried out \ncompletely, as well as to prevent the recurrence of the \ndisease25-27.\nThere are multiple therapeutic alternatives available \nfor the management of endometriosis. Non-steroidal \nanti-inflammatory drugs are a widely used option in the \ntreatment of chronic inflammatory diseases and have \nbeen shown to be effective in relieving primary dys -\nmenorrhea. Combined oral contraceptives (COCs) and \nprogestins, which are available in various presentations \nand routes of administration, represent the first line of \nhormonal treatment due to their efficacy and safety \nprofile. In cases where these therapies are not suffi -\ncient, the second line is mainly composed of gonado -\ntropin-releasing hormone agonists. Although these \nagents have shown positive results in women who do \nnot respond to COCs or progestins, it is important to \nmention that they require the addition of complemen -\ntary treatments. On the other hand, the use of danazol \nhas decreased significantly due to the availability of \nhormonal options with a superior safety profile and \nbetter tolerability. Since there are few data available on \nthe long-term efficacy and safety of aromatase inhibi -\ntors, they should be given only to women with symp -\ntoms refractory to other conventional therapies in a \nclinical research setting 26,28-31.\nStudies have shown that Vitamin C and Vitamin E \nsupplementation is effective in reducing the severity of \ndysmenorrhea and improving dyspareunia, as well as \ndecreasing the intensity of pelvic pain in patients with \nendometriosis 32-34.\nConclusion\nEndometriosis with terminal ileum involvement is a \nrare and difficult to diagnose entity that can mimic mul -\ntiple entities. This pathology should be suspected in all \nwomen of childbearing age who show intestinal \n\nJ.M. Ruvalcaba-Vallarta et al.  Intestinal endometriosis as cause of stenosis\n5\nsymptoms without apparent causes traditionally demon-\nstrable as if it were a functional digestive disorder, \nespecially because of the implications that emergency \nsurgery can have. Minimally invasive surgery should be \nconsidered the standard of management due to its \nwidely demonstrated benefits, as well as a follow-up in \nconjunction with the gynecology service.\nAcknowledgments\nThe authors would like to thank the pathology service \nof the Hospital General Agustin O’Horan, as well as all \nthose who collaborated in the management of the \npatient.\nFunding\nThe authors declare that they have not received \nfunding.\nConflicts of interest\nThe authors declare no conflicts of interest.\nEthical considerations\nProtection of humans and animals.  The authors \ndeclare that no experiments involving humans or ani -\nmals were conducted for this research.\nConfidentiality, informed consent, and ethical \napproval. The authors have followed their institution’s \nconfidentiality protocols, obtained informed consent \nfrom patients, and received approval from the Ethics \nCommittee. 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