{"paper_id":"b2c7b4cb-3571-4f41-9cbb-af0470744dae","body_text":"International Journal of Case Reports and Images, Volume 15, Issue 1, 2024; Pages 44–49. ISSN: 0976-3198\nInt J Case Rep Images 2024;15(1):44–49.   \nwww.ijcasereportsandimages.com\nChen et al. 44\nCASE REPORT  PEER REVIEWED | OPEN ACCESS\nAn unusual case of bowel obstruction secondary to  \nendometriosis\nYi-Che (Albert) Chen, TY Chuang, J Chen, JY Cheong\nABSTRACT\nIntroduction: Endometriosis is a common disease of \nwomen of childbearing age. It can affect the intestines in a \nportion of patients, although it is generally asymptomatic.\nCase Report:  Here we present an unusual case of a \nlarge bowel obstruction due to intestinal endometriosis.\nConclusion: In the absence of signs or risk factors \nfor colorectal malignancy, endometriosis should be \nconsidered in the differential diagnosis for large bowel \nobstructions occurring in women of fertile age.\nKeywords: Bowel, Endometriosis, Obstruction\nHow to cite this article\nChen YC, Chuang TY, Chen J, Cheong JY. An unusual \ncase of bowel obstruction secondary to endometriosis. \nInt J Case Rep Images 2024;15(1):44–49.\nArticle ID: 101443Z01YC2024\n*********\ndoi: 10.5348/101443Z01YC2024CR\nYi-Che (Albert) Chen1, TY Chuang2, J Chen3, JY Cheong4\nAffiliations: 1Principal House Officer, Department of Surgery, \nIpswich Hospital, Ipswich, Queensland, Australia; 2Registrar, \nDepartment of Surgery, Ipswich Hospital, Ipswich, Queens -\nland, Australia; 3Principal House Officer, Department of Sur -\ngery, Rockhampton Hospital, Rockhampton, Queensland, \nAustralia; 4Consultant, Department of Surgery, Rockhampton \nHospital, Rockhampton, Queensland, Australia.\nCorresponding Author: Yi-Che (Albert) Chen, 6 Lorrimore St, \nMacgregor, Brisbane, Queensland, Australia; Email: Yi-Che.\nChen@health.qld.gov.au \nReceived: 06 November 2023\nAccepted: 05 December 2023\nPublished: 13 March 2024\nINTRODUCTION\nEndometriosis is a common disease affecting 4–17% \nof women of childbearing age [1, 2]. It is the extra-uterine \ndeposition of endometrial tissue and affects the intestine \nin 3–37% of all patients with pelvic endometriosis but \nit is generally asymptomatic in nature [3]. In intestinal \nendometriosis, the endometrial tissue infiltrates the \nbowel wall through the subserosal fat and usually into the \nmuscularis propria [4]. This is termed Deep Infiltrative \nEndometriosis (DIE) which is defined as either >5 mm \nof invasion of endometrial tissue through the peritoneum \nor endometrial tissue invading below the peritoneum \nregardless of depth [5]. The recto-sigmoid colon is the \nmost commonly affected site and accounts for 70% of \ncases and this is followed by the terminal ileum in 5–10% \nof cases and the appendix in 5% [2, 6]. They can present \nwith symptoms of abdominal pain, rectal pain, tenesmus \nand rectal bleeding, constipation, and nausea and \nvomiting which tend to be worse during menses and can \noften be mistaken as menstrual pain [1]. Only in very rare \ncircumstances does intestinal endometriosis cause acute \nbowel obstruction requiring urgent surgical resection [1].\nHere we report a rare case of acute large bowel \nobstruction (LBO) secondary to endometriosis requiring \nsurgical resection, with the diagnosis being made only on \nhistopathology postoperatively.\nCASE REPORT\nA female in her 30s presented to the Emergency \nDepartment (ED) with a one week history of severe central \nabdominal pain and a single episode of feculent vomiting \non the morning of presentation. Prior to this she had a \n5-week history of severe abdominal discomfort which \nshe attributed toward her irritable bowel syndrome (IBS) \nflare up. During this 5-week period she also reported only \nopening her bowels three times. She denied any urinary or \nconstitutional symptoms. She did not have any significant \nalcohol usage history and was a non-smoker. Her past \nmedical history otherwise included attention-deficit \nhyperactivity disorder, anxiety, irritable bowel syndrome \n(IBS), and polycystic ovarian syndrome (PCOS). She did \nnot have any previous abdominal surgical history or any \n\nInternational Journal of Case Reports and Images, Volume 15, Issue 1, 2024; Pages 44–49. ISSN: 0976-3198\nInt J Case Rep Images 2024;15(1):44–49.   \nwww.ijcasereportsandimages.com\nChen et al. 45\nhistory of inflammatory bowel disease (IBD) or personal \nor family history of bowel cancer.\nPrior to presentation, she presented to her General \nPractitioner (GP) and had a computed tomography (CT) \nabdomen and pelvis which showed significant fecal \nloading but no evidence of bowel obstruction (Figure 1). \nShe had two fleet enemas and stimulant laxatives after \nthis with no effect and subsequently attempted bowel \npreparation at home. She was unable to tolerate this and \npresented to the ED the following morning.\nShe was admitted under the local General Surgical \nteam and a nasogastric tube (NGT) was inserted and \nbowel preparation was administered via this. She then \nproceeded to have an abdominal X-ray (AXR) with \nrectal contrast to minimize radiation exposure in this \npatient given she has had a recent CT. The AXR showed \nprominent small bowel loops and dilated large bowel \nwithout any rectal contrast progressing through the \nrecto-sigmoid junction raising the concern for bowel \nobstruction (Figure 2).\nOn day 3 of admission, she developed worsening \nabdominal pain and had a 1.5 L vomit despite the NGT \nbeing still in situ and on free drainage. An urgent CT \nabdomen and pelvis with intravenous (IV) contrast was \nperformed which showed mid-rectal stricture of 40 mm \nin length 20 cm from anal verge, with proximal dilatation \nand an incompetent ileocecal valve (Figure 3).\nFlexible sigmoidoscopy confirmed narrowing of the \nlarge bowel at 20 cm from the anal verge with significantly \ninflamed mucosa, and a narrow opening less than 5 mm \nin diameter which did not allow passage of the scope. The \npatient underwent an emergency Hartmann’s procedure \n(Figures 4 and 5).\nThe postoperative recovery was complicated by \na parastomal hernia on postoperative day (POD) 4 \n(Figure 6), which required take back to theater and \nrefashioning the stoma trephine. On POD10, she developed \na small parastomal abscess collection which was managed \nnonoperatively with intravenous antibiotics.\nThe final pathology showed no evidence of colorectal \nmalignancy. Histopathology showed extensive \nendometriosis with deep implants of endometrial glands \nwithin the mesentery, serosal surface, and muscularis \npropria. On immunohistochemistry the stromal and \nepithelial cells were estrogen receptor (ER) positive and \nthe stromal cells were positive for CD10. This confirmed \nthe diagnosis of DIE which caused external compression \nof the rectum leading to large bowel obstruction.\nRetrospectively, the patient noted that the start of her \ndiscomfort had coincided with her cessation of her oral \ncontraceptive pill (OCP) which she had been taking since \nher teenage years for management of her painful periods. \nAn inpatient gynecological consultation was sought for \nongoing management of her endometriosis and she was \nreferred to the Specialist Endometriosis clinic at a tertiary \nhospital.\nShe was discharged after 19 days of admission and \nfollowed up in the outpatient clinic.\nFigure 1: Non-contrast computed tomography abdomen \nand pelvis organized by the General Practitioner prior to \npresentation which showed significant fecal loading throughout \nthe colon with a collapsed rectum.\nFigure 2: Abdominal X-ray after injection of 250 mL of rectal \ncontrast. The X-ray shows dilated loops of large and small bowel \nwith no progression of rectal contrast beyond the recto-sigmoid \njunction which is concerning for bowel obstruction at the recto-\nsigmoid junction. \nFigure 3: Repeat computed tomography scan with intravenous \nand rectal contrast on day 3 of admission showing an irregular \nthickened 4 cm segment of large bowel (as indicated by \nthe arrow). This appeared to be stricturing the lumen and \npreventing progression of the rectal contrast proximally which \ngives concern for large bowel obstruction.\n\nInternational Journal of Case Reports and Images, Volume 15, Issue 1, 2024; Pages 44–49. ISSN: 0976-3198\nInt J Case Rep Images 2024;15(1):44–49.   \nwww.ijcasereportsandimages.com\nChen et al. 46\nDISCUSSION\nEndometriosis is a benign gynecological disease \naffecting up to 17% of menstruating women which \ninvolves the extra-uterine deposition of endometrial \ntissue [7–9]. There are three main forms of pelvic \nendometriosis including peritoneal, ovarian, and DIE \nwhich encompasses the most common sites of deposition \nincluding the ovaries, pouch of Douglas, uterosacral \nligaments, and the fallopian tubes [5, 7–9]. In Australia, \naround 11% of women are diagnosed with endometriosis \nby the age of 44 and it has been shown to affect around \n70% of women with chronic pelvic pain [10, 11]. \nEndometriosis is one of the leading causes of primary and \nsecondary infertility in up to 30% of women [12]. \nThe etiology of endometriosis is complex and \nmultifactorial involving hormonal changes, genetic \nchanges, and changes in the immune system [13–15]. \nCurrently the most widely accepted pathogenesis of \nendometriosis is the theory of retrograde menstruation \nwhere endometrial tissues reflux through the fallopian \ntubes during menstruation to enter the abdominopelvic \ncavity to implant on the serosal surface of various organs \n[12]. It most commonly deposits in the pelvic peritoneum, \novaries, and rectovaginal septum but has been shown \nin very rare circumstances to involve the pleura, \npericardium, small and large intestines, diaphragm, and \nother tissues [16]. Intestinal endometriosis is the most \ncommon extra-pelvic site of implantation and is found \nin 3–37% of all patients with pelvic endometriosis [9, 11, \n17–19].\nThe classical presentation of patients with \nendometriosis is the triad of dyspareunia, dysmenorrhea, \nand infertility; however, it should also be considered \nin any female patients presenting with chronic pelvic \npain, painful defecation, and/or urinary symptoms \nwith menstruation [20]. In this case, retrospectively \nthe patient did not describe any dyspareunia as she was \npreviously on the OCP for dysmenorrhea and fertility \nwas unclear as the patient was homosexual and had not \ndesired or attempted to get pregnant.\nEndometriosis is an estrogen-dependent \ninflammatory disease and as such medical treatment aims \nto attenuation this estrogen stimulation with medications \nsuch as the hormonal contraceptive pill, progesterogen, \nand gonadotrophin-release hormone agonists [20]. \nHowever treatment is recommended only when there is \na functional impact such as pain and/or infertility or if \nthere is a systematic impact on the individual [20]. In this \ncase, the patient’s use of the OCP for menstrual regulation \nbut it also controlled her endometriosis thereby masking \nsome of her symptoms leading to a delayed diagnosis. \nThis also leads to questioning of her IBS diagnosis and \nwhether her abdominal pains were truly IBS or secondary \nto her intestinal endometriosis.\nSurgical treatment for endometriosis is largely guided \nby the patient expectation, their response to medical \ntherapy, the effect on their quality of life, their desire \nfor pregnancy, and the location of the endometriosis \n[20]. Generally, a laparoscopic approach is favored and \nspecifically for colorectal endometriosis, management \nincludes rectal shaving of lesions, anterior discoid \nresection, and segmental resection of the affected bowel \nsegment [20]. Conservative resection with rectal shaving \nand anterior discoid resections may reduce the risk of \npostoperative complications and improve gastrointestinal \nquality of life scores but comes with higher rates of \nrecurrence [20]. For lesions infiltrating more than \n20 mm of the rectum, rectal function is comparable \nbetween segmental resection and those that had rectal \nFigure 4: Intraoperative photograph showing the causative \nlesion indicated by the forceps.\nFigure 5: Resection specimen post-Hartmann’s procedure. \n(A) Externally there appears to be a cicatrizing lesion (arrow) \ncausing stenosis and narrowing of the lumen and there also \nappears to be multiple dark spots which may be deposits of \nendometriosis. (B) On opening of the specimen, the segment of \nbowel thickening resulting in stenosis is appreciated (star).\nFigure 6: Repeat computed tomography scan at day 4 \npost-Hartmann’s procedure showing the development of a \nparastomal hernia.\n\nInternational Journal of Case Reports and Images, Volume 15, Issue 1, 2024; Pages 44–49. ISSN: 0976-3198\nInt J Case Rep Images 2024;15(1):44–49.   \nwww.ijcasereportsandimages.com\nChen et al. 47\nshaving and/or anterior discoid resections [20]. However \nsegmental resection is associated with postoperative \nsymptomatic stenosis which may require further surgical \nor endoscopic management [20]. Resection of low rectal \nendometrial bowel deposits within 5 cm of the dentate \nline via either segmental or conservative resection is \nassociated with higher risks of rectovaginal fistulas and \nconsideration may be made for a diverting ileostomy or \ncolostomy [20]. Complete resection of the endometrial \ndeposits is recommended as partial resections with \nresidual endometrial tissue is associated with an increased \nrates of pain recurrence postoperatively and a reduction \nin pregnancy rates postoperatively [20].\nWhile bowel is the most common site of extra-pelvic \nendometriosis implantation, bowel obstruction as a result \nof this is rare and only occurs in 0.1–0.7% of all cases with \nintestinal endometriosis and there are only a few reported \ncases of LBO secondary to endometriosis in literature [7, \n8, 21–23] . Large bowel obstruction is most commonly \ncaused by colorectal malignancy, followed by diverticular \ndisease and volvulus [4, 19, 24]. In the acute setting LBO \nrequires early diagnosis and urgent management as \nupstream dilatation of the bowel and subsequent colonic \nischemia can result in bowel perforation leading to \nperitonitis and sepsis [9]. Radiologically on CT scans it is \ndifficult to differentiate obstruction from endometriosis \nfrom a malignant obstruction [4]. In the emergency \nthe standard of care for large bowel obstruction is still \nresection of the disease segment with potential primary \nanastomosis with or without a covering ileostomy [4]. \nIf primary anastomosis not possible then an end stoma \nwould need to be formed and reversal can be considered \nin the future if appropriate [4]. However there have been \ntwo cases reported in literature where the LBO secondary \nto the endometrial deposits were treated initially with \nendoscopic stenting to allow for resolution of the bowel \nobstruction, with the patient then later undergoing \nan expedited laparoscopic resection with primary \nanastomosis [18, 25]. Both these cases were in young \npatients with prior diagnosis of endometriosis however \nwithout this prior diagnosis, colorectal cancer would be \nthe top differential and stenting is not recommended \nin such a setting. This is due to the fact that stenting as \na bridge to surgery in curable and resectable colorectal \ncancers is associated with a possible risk of higher local \nand overall recurrence rates and with no postoperative \nmortality or morbidity benefit compared to upfront \nsurgery [26]. Additionally with stents there is also the \nrisk of complication in the form of stent migration and \nbowel perforation and the rate of these complications is \neven higher in endoscopic stenting for benign disease \ncompared to stenting in malignant diseases [25, 26].\nCONCLUSION\nWhen women of fertile age present to the emergency \ndepartment with clinical and radiological signs of large \nbowel obstruction, if there are no constitutional symptoms \nor risk factors for colorectal cancer, consideration should \nbe made toward intestinal endometriosis as a causative \nfactor. However management would still be focused on \nurgently alleviating the obstruction and if there are any \nconcerns for a colorectal malignancy, upfront surgical \nresection is recommended over endoscopic stenting to \nrelieve the obstruction.\nREFERENCES\n1. Slesser AA, Sultan S, Kubba F, Sellu DP. 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World J Gastrointest Endosc \n2016;8(4):198–204.\n*********\nAuthor Contributions\nYi-Che (Albert) Chen – Conception of the work, Design \nof the work, Acquisition of data, Analysis of data, \nInterpretation of data, Drafting the work, Revising the \nwork critically for important intellectual content, Final \napproval of the version to be published, Agree to be \naccountable for all aspects of the work in ensuring that \nquestions related to the accuracy or integrity of any part \nof the work are appropriately investigated and resolved\nTY Chuang – Conception of the work, Design of the work, \nAcquisition of data, Analysis of data, Interpretation of \ndata, Drafting the work, Revising the work critically for \nimportant intellectual content, Final approval of the \nversion to be published, Agree to be accountable for all \naspects of the work in ensuring that questions related \nto the accuracy or integrity of any part of the work are \nappropriately investigated and resolved\nJ Chen – Conception of the work, Design of the work, \nAcquisition of data, Analysis of data, Interpretation of \ndata, Drafting the work, Revising the work critically for \nimportant intellectual content, Final approval of the \nversion to be published, Agree to be accountable for all \naspects of the work in ensuring that questions related \nto the accuracy or integrity of any part of the work are \nappropriately investigated and resolved\nJY Cheong – Conception of the work, Design of the work, \nAcquisition of data, Analysis of data, Interpretation of \ndata, Drafting the work, Revising the work critically for \nimportant intellectual content, Final approval of the \nversion to be published, Agree to be accountable for all \naspects of the work in ensuring that questions related \nto the accuracy or integrity of any part of the work are \nappropriately investigated and resolved\nGuarantor of Submission\nThe corresponding author is the guarantor of submission.\nSource of Support\nNone.\nConsent Statement\nWritten informed consent was obtained from the patient \nfor publication of this article.\nConflict of Interest\nAuthors declare no conflict of interest.\nData Availability\nAll relevant data are within the paper and its Supporting \nInformation files.\nCopyright\n© 2024 Yi-Che (Albert) Chen et al. 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