{"paper_id":"b6accac7-5c70-421b-8c91-cdb9c0945cc0","body_text":"Open Access, Volume 3\nCase Report\nwww.jjgastro.com\nReceived: Aug 13, 2023\nAccepted: Sep 20, 2023\nPublished: Sep 27, 2023\nArchived: www.jjgastro.com\nCopyright: © Dong J & Liu C (2023).\n*Corresponding Author: Jie Dong1 & Chengjiang Liu2\n1Department of Gynaecology and Obstetrics, Huzhou \nMaternity & Child Health Care Hospital, Huzhou 313000, \nZhejiang Province, China.\n2Department of General Medicine, Affiliated Anqing First \nPeople’s Hospital of Anhui Medical University, Anqing \n246000, Anhui, China. \nEmail: 1661867371@qq.com & mrliu0420@foxmail.com\nA case of rectal endometriosis misdiagnosed as rectal \nmalignancy on three colonoscopies and biopsies sharing a \ncombined literature review\nAbstract\nBackground: Endometriosis involves the intestine, and its clini-\ncal manifestations are nonspecific and lack of etiological manifes -\ntations. The diagnosis is difficult, which often leads to misdiagno -\nsis. We report a case of endometriosis which was misdiagnosed as \nintestinal malignant tumor after colonoscopy and three biopsies.\nCase presentation:  We reported a 42-year-old woman who \nwent to see a doctor because of anal distension. She was examined \nby three gastrointestinal endoscopists at different levels in differ -\nent hospitals and underwent biopsy at the same time. Combined \nwith clinical manifestations, imaging examination, endoscopic ex -\namination and pathological examination, she was misdiagnosed \nas intestinal malignant tumor, and partial intestinal resection was \nperformed according to the surgical principle of malignant tumor. \nConclusion: Although there are advanced gastrointestinal en -\ndoscopy and imaging techniques, intestinal endometriosis is still \neasy to be misdiagnosed. As our case report shows, after three \ncolonoscopy and biopsy, it is still misdiagnosed as intestinal ma -\nlignant tumor. Further research is needed to improve the ability of \npreoperative diagnosis, which deserves the attention of gastroen-\nterologists and obstetricians and gynecologists.\nYufei Liang1; Lina Mei2; Qipeng Ning2; Jiao Zhang2; Jingying Fei3; Chengjiang Liu4*; Jie Dong1*\n1Department of Gynecology and Obstetrics, Huzhou Maternity & Child Health Care Hospital, Huzhou 313000, Zhejiang Province, \nChina.\n2Department of Digestive, Huzhou Maternity & Child Health Care Hospital, Huzhou 313000, Zhejiang Province, China.\n3Department of Ultrasound, Huzhou Maternity & Child Health Care Hospital, Huzhou 313000, Zhejiang Province, China.\n4Department of General Medicine, Affiliated Anqing First People’s Hospital of Anhui Medical University, Anqing 246000, Anhui, \nChina.\nKeywords: Endometriosis; Intestinal malignant tumor; \nColonoscopy.\nBackground\nEndometriosis (EM) is the presence of functional endome -\ntrial glands and stroma outside the uterine cavity, including the \nskin, lungs, gastrointestinal tract, urinary system, and central \nnervous system. Approximately 3%-15% of women of repro -\nductive age have varying degrees of EM [1,2], affecting approxi-\nmately 190 million women worldwide [3], with the majority of \nEM located in the genital organs, the most abnormal sites being \nthe ovaries, uterosacral ligament, greater ligament, and pelvic \nperitoneum. The most common site of extra-genital endome -\ntriosis is the gastrointestinal tract, accounting for 3.8%-37% [4]. \nColorectal Endometriosis (CEM), a form of deeply infiltrating \nendometriosis, occurs when endometriosis lesions invade the \ncolorectum and infiltrate the plasma layer by more than 5 mm. \nAlthough CEM does not represent a significant proportion of \nthe colonoscopy population, its prevalence is as high as 1% in \nwomen of childbearing age [5]. Rectal endometriosis, first re -\n\nwww.jjgastro.com               Page 2\nCitation: Liang Y , Zhang J, Fei J, Liu C, Dong J, et al. A case of rectal endometriosis misdiagnosed as rectal malignancy on \nthree colonoscopies and biopsies sharing a combined literature review. J Gastroenterol Res. 2023; 3(7): 1160.\nported by Dr. Sampson in 1922 [6], is a deep infiltrating endo -\nmetriosis that invades the colorectum and can cause lower gas-\ntrointestinal symptoms such as diarrhea, blood in the stool, and \nperiodic abdominal pain, which can seriously affect the quality \nof life of women of childbearing age. Also due to its infiltrative \nnature and tendency to produce strictures leading to obstruc -\ntion, the clinical presentation of intestinal endometriosis is of -\nten misdiagnosed as malignancy, especially during surgery, and \nits appearance may also be indistinguishable from malignancy \n[7], which may lead to misdiagnosis. In this paper, we report a \ncase of intestinal endometriosis that was misdiagnosed as in -\ntestinal malignancy on three colonoscopies and tissue biopsies.\nCase presentation\nPatient, female, 42 years old, height 159 cm, weight 61 kg, \nusually regular menstruation, cycle 30 days, period 3-4 days, me-\ndium volume, red color, denied history of dysmenorrhea. 2006 \nfull-term cesarean section, intraoperative hemorrhage, treated \nwith blood transfusion, 2010 cholecystectomy due to “gallblad-\nder stones”. In 1999, she delivered a baby girl at term; in 2006, \nshe delivered a baby girl by cesarean section. On September 22, \n2020, she was admitted to the hospital with “lower abdominal \npain for 8 hours after vigorous activity”. Emergency ultrasound \nshowed multiple fibroids in the uterus (with ruptured fibroids \nat the base of the ectopia?) The uterus was irregularly enlarged \nas large as 2+ months of pregnancy, and a completely convex \nmass was seen at the base of the uterus, about 9x8x5 cm in \nsize, hard, with anisotropic vascular hyperplasia on the surface \nand twisted and exposed blood vessels at the tip of the mass. \nThe left anterior wall of the uterus showed a completely convex \nmass, about 7 x 6 x 4 cm in size, soft and cystic in nature, with \nclear borders, the right wall of the uterus showed a slightly con-\nvex mass about 4 cm in diameter, hard and clear borders, the \nrectal fossa of the uterus was closed, some intestinal tubes and \nbilateral ovarian adhesions with the posterior wall of the uterus \nwere seen, the bilateral fallopian tubes had no obvious abnor -\nmalities with the naked eye, and the umbilical ends were visi -\nble. The intraoperative diagnosis: uterine fibroids (multiple) and \nintestinal adhesions. Intraoperative diagnosis: uterine fibroids \n(multiple) and intestinal adhesions. After the operation, there \nwas obvious abdominal distension and vomiting, and the stand-\ning abdominal plain film suggested: Abdominal intestinal dis -\ntension with fluid flattening (in the shape of “spring” change). \nThe postoperative pathology report suggested: Uterine smooth \nmuscle tumor (several), one with edema and deformation, and \nwas discharged 11 days after surgery.\nOn August 3, 2022 (2-years postoperative), the patient vis -\nited the clinic for six months due to anal swelling, the symptoms \nwere not related to menstrual cycle, and a fecal imaging was \nperformed: The distal part of the rectal jug abdomen was seen \nto be mildly protruding anteriorly during forceful evacuation, \nwith a cystic pouch-like change, about 2.8 cm in length and 0.8 \ncm in depth. The local intestinal lumen of the sigmoid colon was \nslightly narrowed, with an upper and lower range of about 3.3 \ncm, and the margin. The lumen of the sigmoid colon was slightly \nnarrowed, with an upper and lower range of about 3.3 cm, and \nthe margin was not well defined See Figure 1. The intestinal lu-\nmen was slightly narrowed, and the endoscope could barely \npass through. \nConclusion\nColonic occupying lesion (whole abdomen enhanced CT is \nrecommended). The intraoperative pictures are shown in Fig -\nure 2. Further CT examination suggested that: The intestinal \nwall at the junction of sigmoid colon and rectum was thickened \nwith mass-like changes, the range was about 4.4 cm × 2.3 cm, \nthe measured CT value was about 49HU, after enhancement, \nmoderate enhancement was seen, the CT value was about \n75HU, the plasma membrane surface of the intestinal canal \ncorresponding to the lesion was still smooth; the distribution \nand morphology of the remaining abdominal intestinal canal \ndid not show obvious abnormal changes, the mesenteric fat \ngap was still clear, and no obvious enlarged lymph nodes were \nseen. No obvious enlarged lymph nodes were seen. The blad -\nder was full and no significant abnormal density foci were seen \nin the bladder. A small cystic hypodense foci, about 2.4 cm × \n1.7 cm in size, could be seen in the right adnexal area, and no \nsignificant abnormal enhancement was seen after enhance -\nment. The size and shape of the uterus were acceptable, and \nno significant abnormal enhancement was seen after enhance-\nment. The biopsy report after colonoscopy suggested tubular \nadenoma (rectum) with mild heterogeneous hyperplasia of the \nglandular epithelium (low-grade intraepithelial neoplasia). The \npatient was referred to a general hospital for gastrointestinal \nsurgery, where colon cancer was highly considered and a biopsy \nwas performed, which showed tubular adenoma (rectum) with \nlow-grade intraepithelial neoplasia. The patient refused further \ntreatment and returned to the hospital 2 months later with no \nsignificant change in the symptoms of anal distention. After \nMTD discussion, colonoscopy was performed again with the \npatient’s informed consent, and the endoscopist was changed. \nThe lesion was partially excised from the colon with adequate \ninformation, and endometriosis was considered in the intra -\noperative frozen section, and the excised tissue was shown in \nFigure 3. Immunohistochemical results: CK (AE1/AE3) (+), CK20 \n(-), CDX-2 (-),CD10 (+), ER (3+), PR (2+), WT-1 (+), p53 (~5%+), Ki-\n67 (~10%+). All pathological images are shown in Figure 4. See \nFigures 9 and 10 for details. postoperative symptomatic treat -\nment and recovery was good. Postoperative follow-up until the \nwriting of this manuscript the patient was generally well with \nno significant discomfort.\nFigure 1: Defecography image. \n\n\nwww.jjgastro.com               Page 3\nFigure 2: First colonoscopy image.\nFigure 3: Surgical removal of some intestinal tissue samples.\n \nFigure 4: Pathological image. \n4A. Pathological examination of the first colonoscopy biopsy.\n4B. Pathological examination of the second colonoscopy biopsy.\n4C. Pathological examination of the third colonoscopy biopsy.\n4D. Histopatological analysis following particial intestinal resection.\n4E. Immunohistochemical investigation subsequent to particial in-\ntestinal resection.\nDiscussion and conclusion\nEndometriosis is defined as the implantation of the endo -\nmetrium in a location other than the uterine cavity. The patho-\ngenesis of endometriosis is unknown. Several hypotheses have \nbeen established to explain the development of endometriosis, \nincluding retrograde menstruation and ectopic transplantation, \ncorpora cavernosa chemotaxis, medically induced injury, auto -\nimmunity, embryonic theory and stem cell origin, genetic sus -\nceptibility, and hormones [8,9]. The most common sites of en -\ndometriosis are the ovaries (60%), uterosacral ligament (60%), \nand broad ligament (15%) [10]. Extrapelvic endometriosis can \noccur in several sites throughout the body such as the liver, \nlungs, and pericardium [11] (Table 1 shows some of the specific \nsites of endometriosis reported outside the relevant pelvis), but \nthe most frequent site outside the pelvis is the gastrointestinal \ntract. Deep Infiltrative Endometriosis (DIE) is defined as endo -\nmetrial tissue infiltrating the peritoneum to a depth of at least \n5 mm [12] and is one of the most aggressive subtypes of endo-\nmetriosis, often in combination with ovarian and peritoneal en-\ndometriosis, with DIE lesions prevalent in the posterior pelvis, \noften involving multiple sites, most commonly the uterosacral \nligament, and other relatively common sites including the vag -\ninal-rectal septum, urinary tract, and intestinal canal, etc [13].\n Intestinal endometriosis refers to the infiltration of endome-\ntrial glands and stroma from the plasma layer of the intestinal \ncanal to at least the subplasma adipose tissue, whereas colorec-\ntal endometriosis is often located in the subplasma and intrinsic \nmuscular layer, with possible involvement of the submucosal \nlayer, but lesions involving the mucosal layer are relatively rare \n[5]. The exact prevalence is not known, but some retrospective \nstudies have shown that intestinal involvement in patients with \nendometriosis ranges from 5.3% to 12%, with the sigmoid colon \nand rectum being the most frequently involved sites in the GI \ntract [14-28], accounting for 50%-70% [29]. Also in general, ec -\ntopic endometrial tissue in the rectum is usually located in the \nmuscular layer and rarely in the submucosa, and the rectal mu-\ncosa is usually not involved [30]. The pathology did not suggest \nendometriosis in any of the 3 colonoscopies + tissue biopsies, \nwhich was considered to be caused by invasion into the intesti-\nnal lumen but not penetration of the mucosal layer.\nEndometriosis invading specific organs is often associated \nwith corresponding symptoms. The clinical manifestations \nof intestinal endometriosis are mainly blood in the stool, ab -\ndominal masses, intestinal obstruction, followed by paroxysmal \nlower abdominal pain, urgency, diarrhea, and changes in bowel \nhabits [31]. Colorectal endometriosis is rare and usually pres -\nents with nonspecific abdominal pain, dyspareunia, dry stools, \nrectal bleeding or painful defecation [32]. In the initial stage of \ncolorectal involvement, bowel symptoms such as painful def -\necation, abdominal discomfort and diarrhea may occur; when \nthe lesion is large or invades the intestinal mucosa, symptoms \nsuch as constipation and bloody stools may occur, mostly cy -\nclical, aggravated 1 day before or during menstruation, and \nsometimes blood in the stool is not cyclical; in advanced pa -\ntients, complete intestinal obstruction may develop [33]. The \npatient presented with symptoms of intestinal obstruction after \nemergency dissection, which cannot be completely excluded in \nthe current analysis as being due to intestinal endometriosis, \nwhile the patient had anal cramping but no other obvious clini-\ncal symptoms, and the association between anal cramping and \nmenstrual cycle changes was not obvious, and these may also \nbe the reasons why endometriosis was not first considered in \nthe preliminary diagnosis. The obstruction in rectal endome -\ntriosis is mainly associated with transmural involvement form -\ning a stricture or mass, which is mainly due to severe smooth \nmuscle hypertrophy around the endometrial lesion present in \nthe intrinsic myometrium. This phenomenon is similar to the \nformation of uterine adenomyosis [28]. The authors reviewed \nthe relevant literature and made a demonstration for the lo -\ncation, symptoms and treatment modalities of some intestinal \n\nwww.jjgastro.com               Page 4\nendometriosis, as detailed in Table 2.\nTable 2 Some reported sites, symptoms and treatment mo -\ndalities of intestinal endometriosis.\nThe fact that endometriosis involves the intestine, whether \nit occurs in the colorectum or penetrates the muscular layer to \nreach the mucosal layer, its clinical manifestations are nonspe-\ncific and therefore its diagnosis can be very difficult. The lack \nof etiologic manifestations of intestinal endometriosis makes \nits differential diagnosis with other diseases challenging [47] \nand needs to be differentiated from chronic enteritis, ulcerative \ncolitis, Crohn's disease, appendicitis, isolated rectal ulcer syn -\ndrome and especially malignancy, because although they share \nmany clinical symptoms, the treatment approaches are very dif-\nferent [29]. For rectal and sigmoid endometriosis diagnosis can \nbe made by Transvaginal Ultrasound (TVUS), Transrectal Ultra -\nsound (TRUS) and, when a rectal mass is present, abdominal CT \nscan can be used to evaluate rectal endometriosis with variable \nsensitivity. In the patient reported in this paper, CT suggested \nthickening of the intestinal wall but the mucosal surface was \nintact. Combined with the relevant imaging indexes CT diagnos-\ntic opinion also considered the possibility of malignancy, which \nalso had some influence on the late misdiagnosis. And other \nrelated reports suggest that magnetic resonance imaging and \nultrasound may be more sensitive in detecting rectal endome -\ntriosis [48], especially pelvic MRI, which is more commonly used \nabroad in recent years in the examination of deeply infiltrating \nendometriosis because of its superiority to CT in imaging the \nsoft tissues of the pelvis, which can provide information on the \ndepth of intestinal wall infiltration, the extent of intestinal wall \nlesions, and the distance between intestinal lesions and the \nanal verge [49,50], Del Frate C et al. Summarize the solid mass \ntype presents with low-intensity signal on T1-weighted images \nmixed with small patchy areas of strong signal that are small foci \nof hemorrhage and homogeneous low signal on T2-weighted \nimages that intensify on enhancement, consistent with a large \namount of fibrous tissue in the lesion on histologic examination. \nIn a 2016 review [51] concluded that no imaging test is superior \nto surgery in the diagnosis of endometriosis. However, with the \ndevelopment of imaging techniques such as ultrasound, imag -\ning is becoming more sensitive in the diagnosis of endometrio -\nsis [52,53].\nWith the development of intestinal endoscopic techniques, \nnew advances have been made in the diagnosis of intestinal \nendometriosis. Since the site of colorectal endometriosis is the \nanterior rectal wall and the anterior lower border of the sig -\nmoid colon, growing from the plasma membrane layer into the \nintestinal lumen, enteroscopic manifestations are mostly signs \nof submucosal or extra-mural masses, which may be normal on \nthe mucosal surface, but may show congestion, edema and su-\nperficial ulcers, sometimes inflammatory polyps, occasionally \ndark purple hemorrhagic spots in the submucosal layer, eccen-\ntric mucosal wrinkles, aggregates in the invaded intestinal ca -\nnal, and the presence of fibrosis in Jiang W et al. [53] described \n15 patients with intestinal mucosal endometriosis, whose mu -\ncosal changes were mainly characterized by (1) replacement \nof the intestinal mucosal surface epithelium by endometrial \nglands, (2) mingling of intestinal mucosal glands with endome -\ntrial glands, and (3) mixing of endometrial glands with intesti -\nnal mucosal glands. The glands are surrounded by endometrial \ninterrogative cells, and the interrogative mass is seen to have \nhemorrhagic and edematous changes. The endometrial glandu-\nlar epithelial luminal margin may be mildly serrated and irregu-\nlar, lined with a single layer of epithelium, with tall columnar \ncells with cigar-shaped growing nuclei, acidophilic cytoplasm, \nno cellular secretion, ciliated (tubal epithelium) metaplasia, and \nother metaplasia such as squamous metaplasia, or significantly \ndilated glandular lumen with flattened lining epithelium. How -\never, some endoscopic presentations lack specificity, so some \nphysicians choose to perform simultaneous biopsies at endos -\ncopy for suspicious sites. Endoscopic biopsies often obtain tis -\nsue that only reflects chronic injury but may lack a basis for a \ndefinitive diagnosis of endometriosis lesions, so this may lead \nto misdiagnosis [47]. Kim et al. [54] reported a positive rate \nof colonoscopic biopsies of only 47.0% (8/17), but their study \nhypothesized that increasing the number of biopsies may help \nto improve the positive rate of biopsies. The superficial mu -\ncosa of endometriosis lesions has more obvious inflammatory \nmanifestations, and in some cases cryptitis, crypt abscesses \nand other pathological manifestations similar to inflammatory \nbowel disease can be seen [53], thus having an impact on the \ninterpretation of pathological findings. The colonoscopic pre -\nsentation and biopsy pathology of endometriosis lesions can be \nindistinguishable from inflammatory bowel disease, ischemic \nbowel disease, or even colonic malignancy, which may lead to \nunnecessary surgical treatment. Studies have reported that im-\nmunohistochemistry (CK7, ER, CK20, and CDX2) can help im -\nprove the diagnosis in cases of diagnostic difficulties [55]. The \npatient underwent 3 colonoscopies, and although the endos -\ncopists were different on all three occasions, the microscopic \nmanifestations all showed raised intestinal mucosal lesions, and \nthe microscopic manifestations all first considered intestinal \nmalignancy, because the lesions invaded the muscular layer but \ndid not reach the mucosal layer, so although the specificity of \nthe endoscopic manifestations was not obvious compared with \nmalignancy, and the pathological results of all 3 biopsies did not \nsuggest endometriosis, they were all diagnosed as low-grade. \nThis is consistent with reports suggesting some difficulties in \npathological diagnosis.\nThe treatment of endometriosis aims to reduce and elimi -\nnate lesions, alleviate and eliminate pain, improve and promote \nfertility, and reduce and avoid recurrence [56], Currently, drugs \navailable for the treatment of endometriosis include denoges -\ntrel, oral contraceptives, GnRH-a and non-steroidal anti-inflam-\nmatory analgesics, especially denogestrel because it can effec -\ntively control pain without producing hypoestrogenemia. It is \nnow the first-line treatment drug [57]. However, medications \ncan reduce symptoms but do not completely cure the disease \nand are often associated with side effects [58], while proges -\nterone and gonadotropin-releasing hormone analogs can be \nused for women with intestinal strictures <60% and who want \nto avoid surgery [58]. When hormonal therapy fails, surgery is \nthe treatment of choice. Especially when the patient presents \nwith intestinal obstruction or severe endometriosis, the only \ntreatment is surgical excision due to myocyte proliferation and \nfibrosis of the endometriotic tissue in the intestinal muscular \nlayer [7]. For the treatment of intestinal endometriosis, total \nanterior resection is feasible for single infiltrating nodules, ap -\nproximately 30 mm in size and less than one-third of the intes -\ntinal circumference, whereas more extensive infiltrating lesions \nrequire formal excision and anastomosis. The most common \ntreatment for endometriosis in the rectosigmoid colon is cur -\nrently partial resection [59]. Bowel resection is also considered \nthe recommended treatment for patients with bleeding and \nsuspected malignancy [60], the goal of surgical treatment is to \nremove all visible areas of endometriosis lesions and for some \n\nwww.jjgastro.com               Page 5\nauthors it should be as radical as possible, just like cancer sur -\ngery [61], including rectal segmental resection [62], but there \nare no more scientific studies reporting on the extent of bowel \nresection and whether the extent of resection is required is the \nsame as for colon. There is no uniformity in the extent of resec-\ntion for rectal cancer, and we know that inappropriate radical \nsurgery can result in permanent stoma and reduced quality of \nlife, so it is more important to be able to distinguish intestinal \nendometriosis from intestinal cancer preoperatively, and ad -\nequate biopsy specimens should be examined histopathologi -\ncally to confirm the diagnosis and guide treatment. In contrast, \nanother opinion is that when endometriosis invades the mu -\ncosal layer, conservative treatment such as lesion excision (i.e., \nremoval of endometriosis nodules in contact with the intestinal \nplasma membrane without opening the rectal lumen) should \nbe preferred to reduce the associated functional sequelae [63]. \nAnd in a study of 26 patients with rectosigmoid endometrio -\nsis, issue 42.3% had lymph node involvement and 36.3% had \nlymphovascular invasion [64], while on rapid frozen section ex-\nTable 1: Selected extra-pelvic specific sites of endometriosis.\nCase Age Involved site Symptom Therapy method\nHeijink T. 2020 [14] 31 The Bartholin gland Cyclical vulvar pain Surgical excision\nOner A. 2006 [15] 28 Nasolacrimal A cyclical bleeding from puncta of the eyes No\nPascoal E.2021 [16] 39 In the medial left thigh, inferior to the \npubic ramus, near the gracilis muscle Catamenialpain Surgical excision\nAboujaoude N.2021 [17] 34 Pulmonary Cyclic hemoptysis A GnRH agonist\nSherif AM.2016 [18] 44 Subcapsular hepatic Progressive right upper quadrant pain and \nvomiting Surgery\nHeinz Bacher, M.D [19] 24 The external anal sphincter The perianal pain to her menses Surgery\nYokota N. 2008 [20] 37 Cervical A severe vaginal hemorrhage\nUterine artery embolization, The \nhemorrhage could not be stemmed by \nwound suture and vaginal tamponade.\nWolthuis AM.2016 [21] 28 Diaphragmatic Catamenial right hypochondrium and right \nshoulder-pain Surgical excision\nChristable E.2021 [22] 26 Endometriosis of para- aortic Lower abdominal pain Surgery\nNigam A. 2013 [23] 32 In the lower abdominal wall in the region \nof the caesarean scar in the lateral part. Cause of deep dyspareunia Surgery\nNewme K.2021 [24] 42 Umbilical Blood coming from umbilicus and had a \nhistory of dysmenorrhea\nFollowed-up in outpatient department \nfor 3 years, Symptoms improved after \nmenopause\nCharpentier E. 2018 [25] 42 Pericardial Unexplained chronic and catamenial chest \npain Nomegestrol\nPatel VC.1982 [26] Knee Painful swelling on the lateral aspect of the \nright knee Danazol\nYang Y . 2021 [27] 48 Renal Intermittent gross hematuria Mimicking cystic renal tumor and surgi-\ncal removal of mass\namination, endometriosis in the rectum may be mistaken for \ncancer because glands in the rectal muscularis may be mistaken \nfor cancer infiltration [65], which further increases the difficulty \nof clinical diagnosis and treatment. However, we need to know \nthat the chance of malignant endometriosis is about 0.7% to \n1% and it occurs less frequently in the colorectum [66], so the \nchoice of surgical approach for this group of patients should be \nmade carefully to avoid avoid avoidable sequelae for the pa -\ntients.\nThe clinical symptoms of intestinal endometriosis lack speci-\nficity, while the endoscopic performance lacks specificity and \nthe positive pathology rate is low, so it is easy to be misdiag -\nnosed. The case was finally misdiagnosed as intestinal malig -\nnant tumor by 3 times of colonoscopy and biopsy, and seg -\nmental bowel resection was performed according to malignant \ntumor. This case reminds clinicians to pay attention to the diag-\nnosis and treatment of intestinal endometriosis, especially to \nimprove the diagnosis before treatment, and reduce the physi-\ncal trauma and economic burden of patients.\nTable 2: Some reported sites, symptoms and treatment modalities of intestinal endometriosis.\nCase Age Involved site Symptom Therapy method\nHas a previous \ndiagnosis of endome-\ntriosis been made\nBuldanlı MZ.2020 [34] 40 Sigmoid colon Intestinal obstruction Resected totally respect to oncological \nprinciples and do colostomy. No\nGregorić P . 2012 [35] 41 Distal Ileal Intestinal obstruction Ileum Resection, and a termino-ter-\nmino EE anastomosis yes\n\nwww.jjgastro.com               Page 6\nYilmaz B. 2014 [36] 42 Sigmoid colon Rectal bleeding\nSegmental resection of the\nsigmoid colon with side-to-side anasto-\nmosis was performed\nNo\nIndraccolo U. 2010 [37] 36 Cecal Ileocolic Intussusception Laparoscopic debulking of the endome-\ntriosis, and right hemicolectomy Yes\nMarklund A. 2019 [38] 30 Rectosigmoid \ncolon\n2 weeks interval abdominal \npain and a 4 days' history of  \nobstipation\nNeoadjuvant treatment that included \nradiotherapy and chemotherapy,later \ndo rectum and a bilateral salpingo-\noophorectomy \nNo\nAlvarado LER.2021 [39] 41 Rectal\nComplete large bowel obstruc-\ntion complicated by sepsis and \ntoxic megacolon\nTotal colectomy with ileostomy No\nAllan Z. 2018 [40] 37 Large bowel Large bowel\nobstruction\nLaparoscopic wedge resection of recto-\nsigmoid tumour with primary anastomo-\nsis and endoscopic decompression\nyes\nGarg NK.2009 [41] 44 Colon Colonic perforation A proximal colostomy was performed \nand the endometriotic mass resected Yes\nLee M. 2021 [42] 35\nAt the cecum near \nthe appendiceal \norifice\nFetal demise and \ngastrointestinal hemorrhage\nSymptomatic treatment such as blood \ntransfusion and have a colonoscopy \nafter delivery\nNo\nAragone L. 2023 [43] 39 Appendiceal A week of abdominal pain was \ndiagnosed as appendicitis Appendectomy No\nAlabbas H. 2019 [44] Reports not \nprompted Small Bowel Recurrent semi-obstructive \nsymptoms Right hemicolectomy\nOvarian cysts were  \nremoved but the  \narticle did not  \nmention if it was endo\nMittelstadt S. 2022 [45] 28 The sigmoid colon Sigmoid perforation\nAn exploratory laparotomy with C-\nsection, . and A partial sigmoid resection \nwith side-to-side anastomosis was\nperformed\nNo\nNishikawa A. 2013 [46] 38 Ileum Ileal perforation and massive \nintestinal haemorrhage\n33+5 underwent cesarean section with \nRight hemicolectomy and terminal ileum \nresection\nYes\nDeclarations\nContributors: L.Y .F. , C.J.L. and D.J. designed the study and \nsupervised the overall project. M.L.N. N.Q.P . Z.J and F.J.Y . partici-\npated in data. collecting and analysis. L.Y .F. provided the statisti-\ncal analysis and wrote the manuscript.\nConflict of interest: The authors declare that they have no \nconflict of interest.\nFunding: No funding.\nEthical standards: Written informed consent was obtained \nfrom the patient. This paper was approved by Huzhou Mater -\nnity & Child Health Care Hospital (number: 2023-J-072), and we \nwere in accordance with the 1975 Helsinki declaration and its \nlater amendments.\nData availability: The data that support the findings of this \nstudy are available on request from the corresponding author.\nReferences\n1. Zanelotti A, Decherney AH. Surgery and Endometriosis J. Clin \nObstet Gynecol. 2017; 60: 477-484.  \n2. Arafat S, Alsabek MB, Almousa F, et al. Rare manifestation of en-\ndometriosis causing complete recto-sigmoid obstruction: A case \nreportJ.Int J Surg Case Rep. 2016; 26: 30-33.\n3. Horne AW, Missmer SA. 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