{"paper_id":"bfa675f4-1923-46c5-91c8-3fd9c7087d4c","body_text":"© 2014 Asociaciones Colombianas de Gastroenterología, Endoscopia digestiva, Coloproctología y Hepatología\n156\nCase report\nDumar Rodríguez Tello, MD,1 William Otero Regino, MD,2 Martín Gómez Zuleta, MD.3\nEndometriosis in the Colon with Intestinal \nObstruction: Case Report and Literature Review\n1  Emergency Medicine Physician at the Clínica \nFundadores in Bogotá, Colombia\n2  Professor of Medicine in the Gastroenterology \nUnit at the Universidad Nacional de Colombia and \nGastroenterologist at the Clínica Fundadores in \nBogotá, Colombia\n3  Professor of Medicine in the Gastroenterology \nUnit at the Universidad Nacional de Colombia and \nGastroenterologist at the Hospital El Tunal and \nHospital de Kennedy in Bogota, Colombia\n.........................................\nReceived:    27-08-13  \nAccepted:    08-15-14\nAbstract\nEndometriosis is a condition that primarily affects women of reproductive age since the intestinal tract is the \nmost commonly affected extra-genital site. Its clinical presentation varies, but since it rarely presents together \nwith intestinal obstruction, it is difficult to differentiate from malignancy prior to surgery. Colorectal compromi-\nses can mimic or coexist with different chronic gastrointestinal diseases thus hindering diagnosis. We report \nthe case of a 48 -year-old patient with box intestinal obstruction secondary to endometriosis in the sigmoid \ncolon. In addition, we present a literature review of intestinal endometriosis with emphasis on differential \ndiagnosis and the involvement of bacterial infections in the etiology and reactivation of endometriosis.\nKeywords\nEndometriosis, intestinal obstruction, infection.\nINTRODUCTION\nEndometriosis (EMT) is defined as a chronic inflamma -\ntory condition characterized by the presence of endome -\ntrial glands and stroma outside the uterus (1). Its discovery \nis controversial, John Sampson is commonly considered to \nhave made the first pathophysiology description, but his \nwork would not have been possible without the contribu -\ntion of Thomas Cullen (2). EMT is an estrogen dependent \ncondition, commonly associated with chronic pelvic pain \nand infertility. It affects between 6% and 10% of reproduc-\ntive age women, but its prevalence increases to between \n30% and 50% in infertile women (1). It commonly mani -\nfests in the peritoneum, ovaries, rectovaginal septum, pul -\nmonary system, central nervous system, skin and striated \nmuscles (3, 4).\nThe intestinal tract is the most commonly affected extra \ngenital area (3, 5). Prevalence varies from 5.3% to 12% (4, \n6, 785 patients (5.4%). The average age at presentation is \n39 years (5). The most frequent location is the rectosig -\nmoid (71%), followed by the appendix (19%), terminal \nileum (6.7%), cecum (5.5%) and the transverse colon \n(0.5%) (3, 4, 6-8). \nWhen the intestines are involved, the main symptom \nis abdominal pain that worsens during the menstrual \nperiod (3, 7-9). 85 patients (5.4%Other symptoms include \nchanges in intestinal habits, cyclical rectal bleeding, dys -\nchezia, rectal tenesmus, abdominal distension, diarrhea, \nrecurrent constipation and, occasionally, partial or com -\nplete intestinal obstruction and palpable abdominal masses \n(6, 885 patients (5.4%).\nWe present the case of a patient, and we review the lit -\nerature. The patient was admitted to our institution with \nan intestinal obstruction due to endometriosis in the sig -\nmoid colon. \nCLINICAL CASE\nA 48 year old woman entered the intensive care unit at the \nFundadores Clinic in Bogota. She had been suffering from \n\n157\nEndometriosis in the Colon with Intestinal Obstruction: Case Report and Literature Review\npersistently decreased caliber of her feces, diffuse posterior \nabdominal pain, vomiting and abdominal distension for \n10 days. Her medical history included dysmenorrhea, ute -\nrine fibroids, iron deficiency anemia and left urolithiasis. A \nmonth and a half before admission to our clinic, she had \nbeen hospitalized for 12 days with E. coli pyelonephritis \nwhich had been treated with meropenem. After treatment, \nshe developed colitis secondary to c. difficile and was trea-\nted with metrodinazole, but without improvement. She \nwas switched to oral vancomycin for 10 days. This resolved \nthe clinical presentation. While hospitalized the second \ntime, a colonoscopy was performed. It found a sigmoid \nstenosis located 28cm from the rectum that could not be \nremoved. Biopsies taken from that site showed no altera -\ntions. A double contrast enema with was performed, but it \nwas not possible to visualize the whole colon. A complete \nabdominal CAT scan with contrast showed sigmoid thic -\nkening (Figure 1).\nFigure 1. CAT scan of the contrasted abdomen shows segmental \nthickening of the sigmoid colon walls and myoma in the uterus. \nWith a diagnosis of stenosis and partial intestinal obstruc-\ntion, laparoscopic en-bloc resection of the sigmoid colon \nand a Hartmann colostomy were performed. The surgery \nuncovered an inflammatory process and fibrosis in the \npelvis. Consequently, the gynecologist performed a hyste -\nrectomy and a bilateral salpingo-oophorectomy. The results \nfrom pathology were, “ …endometriosis in the sigmoid \ncolon. The muscularis is infiltrated by stroma and endo -\nmetrial glands, and there is edema and vascular congestion \nin the mucosa. Tumor processes were not identified. The \novaries and left fallopian tube have endometriosis. ”\nINTESTINAL OBSTRUCTION RESULTING FROM \nENDOMETRIOSIS\nIntestinal obstruction secondary to EMT is an infrequent \npathology, occurring in less than 1% of all cases (10). In a \nstudy with 163 patients with intestinal EMT , ten patients \npresented partial intestinal obstructions (11). In most \ncases, obstruction was not initially diagnosed but was \ndiscovered in the pathology results. Intestinal obstruction \nmay occur in patients with intestinal EMT who may conco-\nmitantly presently colonic neoplasia (12). In a study with \n16 cases of intestinal obstruction due to endometriosis, \nmicroscopic findings showed a greater concentration of \nglands and stroma in the serosa and the external muscular \nlayers when the ileum was compromised while obstruc -\ntions in the sigmoid have greater implications for the inner \ncircular muscle and the submucosa (13).\nIntestinal EMT manifests as superficial or profound \nlesions. The most frequently affected intestinal layer is the \nserosa, followed by the muscularis propria (12, 14). The \nsuperficial lesions endanger the serosa and are generally \nthe size of the head of a pin and surrounded by scarce fibro-\ntic tissue (5). The deepest lesions endanger the muscularis \npropria or even the submucosa and mucosa in patients with \ngastrointestinal symptoms (4, 15).  This involvement pro-\nduces secondary fibrosis which provokes thickening of the \nwall and decreases the intestinal lumen. When endometrial \nlesions affect the rectum and/or sigmoid colon beyond the \ninternal muscular layer and more than 40% of the circumfe-\nrence of these organs is compromised, the recommenda -\ntion is segmented intestinal resection (16).\nEndometriosis affected the sigmoid muscular layer in the \ncase described above. \nDIFFERENTIAL DIAGNOSIS\nColorectal EMT can imitate or coexist with various other \ngastrointestinal diseases such as Crohn’s disease, ulcera -\ntive colitis, ischemic colitis, diverticulitis, irritable bowel \nsyndrome, and even colon and rectum tumors when intra -\nluminal endometriomas are present. This can complicate \ndiagnosis which can lead to aggressive surgical treatment \nassociated with high morbidity and mortality (6, 17, 18and \nevaluated them for a variety of gross and histologic changes. \nCases with preneoplastic or neoplastic changes were exclu-\nded specifically because they were the subject of a previous \n\n\nRev Col Gastroenterol / 29 (2) 2014\n158\nCase report\nstudy. The patients ranged in age from 28 to 56 years (mean \nage, 44 years). In a case and control study of 5,540 women \nwith endometriosis, there was a higher probability of being \ndiagnosed with irritable bowel syndrome among women \nwith endometriosis than among women in the control \ngroup (OR 3.5 CI 95%, 3.1–3.9). There was also a higher \nprobability of being treated for inflammatory pelvic disease \nbefore (OR 5.9 CI 95%, 5.1–6.9) and after (OR 3.8 CI \n95%, 3.1–4.6) being diagnosed with endometriosis (19). \nIn another study of 7,025 women with endometriosis, 65% \nwere misdiagnosed with another condition and 46% were \nseen by five doctors or more before the diagnosis (20). \nWhen the ileum is compromised, the differential diagno -\nsis must check for Crohn’s disease, since both diseases may \nproduce inflammation, hardening, thickening and stenosis \nin the small intestine (21). A study of a cohort of 37,661 \nwomen with endometriosis showed a 50% increase in the \nrisk of inflammatory intestinal disease. This risk persisted \nafter  20 years of monitoring (21).  \nEMT is usually a benign disease, yet it is estimated that \n1% of the cases are associated with cancer, especially when \nboth conditions are present in the ovary. This mainly affects \npostmenopausal woman (21). The frequency of endome -\ntriosis and cancer in the sigmoid colon was calculated \nat 1:156 (5). Malignant tumors should be suspected in \npatients with abdominal pain or rectal bleeding and a pre -\nvious history of quiescent endometriosis, especially when \nthe patient has received estrogen treatment (12). Primary \ncolon carcinomas always involve the mucosa and are often \nassociated with adenomatous changes or a neoplastic polyp \nin the adjacent epithelium. They extend from the mucosa \nthrough the intestinal wall until the serous surface or to the \nadjacent fat (12). In contrast, endometriosis, and the can -\ncers it may harbor, most frequently involve the outermost \nlayers of the intestine wall (occasionally associated with \nadhesions): the serous, sub-serous and muscularis propria, \noccasionally extending into the sub-mucosa (12). Generally \nuseful characteristics that help distinguish neoplasia from \nintestinal endometriosis include the characteristic location \nwithin the intestinal wall with extensive mural involvement \nand less prominent changes in the mucosa, association with \nserositis or post-operational adhesions and the presence of \nsmall mural cysts or hemorrhaging (6).     \nETIOLOGY\nThe etiology of EMT is complex and multifactorial. Several \ntheories try to explain its physiopathology. The theory of \nretrograde menstruation proposed by Sampson in the \n1920’s states that fragments of the endometrium dissemi -\nnate. This is supported by the discovery of menstrual blood \nin the peritoneal liquid in 90% of healthy women with per-\nmeable fallopian tubes who receive laparoscopies during \ntheir premenstrual cycle (23). \nThe theory of coelomic metaplasia involves a transforma-\ntion of the peritoneal tissue to ectopic endometrial tissue \ninduced by hormonal or endogenous immunological sti -\nmulus (23). Another consideration is that the embryonic \nremains of the paramesonephric ducts migrate and have \nthe capacity of developing endometrial lesions under the \ninfluence of estrogens beginning in puberty (23). This \ntheory is supported by a study that found that women \nwhose uteruses were exposed to diethylstilbestrol had a \nrelative risk of 1.8 (CI 95%, 1.2–2.8) of developing endo -\nmetriosis (24). A more recent possibility suggests that \nextra uterine stem cells from bone marrow can be differen-\ntiated into endometrial tissue (23). The support for this \ntheory is derived from cases of histologically confirmed \nendometriosis in patients without menstrual endometrium \nsuch as people with the Mayer-Rokitansky-Küster-Hauser \nsyndrome (MRKH) and men with prostate cancer who \nreceive high dose estrogen treatments (23).\nEMT is a chronic inflammatory disease that involves \nsecondary inflammatory mediators. Primary inflammatory \nmediators like endotoxins or lipopolysaccharides (LPS) \nof gram-negative bacteria can be the triggers of secondary \ninflammatory mediators such as cytokines, chemokines, \nmaturation growth factors or macrophage activation in \nthe pelvis (25, 26). The bacterial hypothesis suggests that \nShigella or similar bacteria can detonate immunological \nchanges in the pelvic peritoneum which initiate etiopatho-\ngenesis of the endometriosis (25). Some patients with \nintestinal EMT present bacterial overgrowth which is spe -\nculated to be secondary to the neuromuscular alteration \nproduced by the entity (26). EMT in Rhesus monkeys is \nassociated with alterations in intestinal microflora in which \nthere is a low concentration of lactobacilli and a high con -\ncentration of Gram-negative bacteria (27). Khan et al. per-\nformed a study which proved for the first time that women’s \nmenstrual blood with endometriosis is more contaminated \nwith Escherichia coli than the blood of women in a control \ngroup. They also showed that women with EMT had hig -\nher levels of endotoxins in their menstrual blood and there-\nfore in the peritoneal liquid due to the reflux of menstrual \nblood in the pelvis (28). This can promote the growth of \nT oll-4 receptor (TRL4) mediated by EMT as evidenced by \nincreased endometrial cell growth in response to LPS and \nthe suppression of these effects mediated by the anti-TLR4 \nantibody (28). In contrast, an experimental endometriosis \nstudy in mice showed no significant difference in the total \nbacterial load or in the number of lactobacilli in experimen-\ntal animal colons when compared to controls (29). The \npatient mentioned in this study presented pyelonephritis \nfrom E. Coli and pseudomembranous colitis from C. difficile \n\n159\nEndometriosis in the Colon with Intestinal Obstruction: Case Report and Literature Review\ntoneal endometriosis, but it is a useful tool for diagnosing \nand, excluding a diagnosis of, ovarian endometriosis (30). \nA multivariate analysis of four biomarkers (annexin V , vas-\ncular endothelial growth factor (VEGF), CA-125 and cell \nadhesion molecule I (sICAM-1) or glycodelin) in plasma \nsamples obtained during the menstrual phase can diagnose \nendometriosis which is undetectable through ultrasound. \nThe sensitivity of this test is 81% to 90% and its specificity \nis 63% to 81%. (20)\nTREATMENT\nT reatment options consist primarily of medical therapy and \nsurgical therapy (34, 35). Segmented laparoscopic resec -\ntion of the rectum and sigmoid colon improve symptoms \nrelated to pain and meet the essential objective of treating \nintestinal endometriosis. Consequently, they significantly \nimprove the patients´ quality of life (34, 35). The hormo -\nnal treatment for suppressing the ovarian function lasts 6 \nmonths and decreases the pain associated with endome -\ntriosis. The most frequently used hormonal medications \nare oral contraceptives, danazol, gestrinone, medroxypro -\ngesterone acetate and agonists of gonadotropin-releasing \nhormone. They are equally efficient, but their secondary \neffects and cost profiles differ (30). Patients with obs -\ntructive symptoms from intestinal EMT should undergo \nsurgical resection (4). Conservative surgery has shown \nbenefits in women who wish to preserve their reproduc -\ntive organs: out of 54 women who underwent conservative \nsurgery, 23 became pregnant (11). When comparing lapa -\nroscopic colonic resection with laparotomy in patients with \nintestinal EMT , both options lead to similar symptomatic \nimprovement after surgery, but those who underwent lapa-\nroscopic treatment had significantly lower rates of surgical \ncomplications and also had the highest rates of sponta -\nneous pregnancy (7, 36). \nCONCLUSIONS\nIntestinal EMT is a pathology that should be clinically sus-\npected in women at reproductive ages as a possible cause \nof diffuse abdominal pain, rectal bleeding and intestinal \nobstruction. Also, intestinal EMT can imitate or coexist \nwith various gastrointestinal pathologies such as neoplasia, \ninflammatory intestinal disease and irritable bowel syn -\ndrome. Additional research needs to be done in order to \ndetermine the role that bacterial infections might have in \nthis pathophysiology since the theoretical possibility exists \nthat they might be related to the etiology itself or to reacti-\nvation of the inflammatory process that leads to EMT . \nbefore the intestinal obstruction from EMT .  It is possible \nthat the inflammatory response from these infectious enti -\nties could reactivate EMT causing an increase in lesions \nand triggering intestinal obstruction. \nDIAGNOSIS\nCurrently, the “gold standard” for a definitive EMT diagno-\nsis is visual laparoscopic inspection with histological confir-\nmation. This also allows ablative and corrective treatment \nin the same surgical treatment (30). Colonoscopy with his-\ntology is rarely used to diagnose intestinal endometriosis, \nunless there are intraluminal lesions. It has low sensitivity \nexcept when there is evident compromise of the mucosa \n(31). However, it is the exam of choice for every patient \nwith rectal bleeding, especially if bleeding is cyclical. It is \nthe first exam performed on patients with rectal bleeding \nsince it can exclude malignancies and other causes of blee -\nding, but it has a low sensitivity for diagnosing colorectal \nendometriosis (32). The most common finding is eccen -\ntric thickening of the wall followed by polypoid lesions. \nThe histological diagnostic performance of endoscopic \nbiopsies is high when lesions are accompanied by super -\nficial nodules, and low when they are not present. This is \nprobably due to the fact that involvement of the colon’s \nmucosa is rare (31). The colonoscopy and the biopsy per -\nformed on our patient showed no evidence of EMT . This \ncorrelates with what is described in the literature. Barium \nenemas with double contrast have been used to diagnose \nintestinal endometriosis (32, 33). The main limitation is \nthe difficulty in differentiating intestinal endometriosis \nfrom other pathologies. Other limitations include the use \nof ionizing radiation in women during reproductive ages, \nthe impossibility of estimating the degree of infiltration \nof the intestinal wall, and identification of extension to \nother pelvic organs (33). Endoscopic rectosigmoid ultra -\nsonography is used to establish the depth of the EMT’s \ninfiltration into the intestinal wall when performed prior \nto surgery. It is possible to distinguish between patients for \nwhom intestinal resection is indicated and those that may \nbe treated with laparoscopic surgery without entering the \nintestine (32). Preoperative magnetic resonance (MR), \nafter cleaning the intestines allows a clear and anatomical \ndelimitation of lesions in the sigmoidal colon and the rec -\ntum (33). The depth of infiltration of endometrial nodules \nin the intestinal wall cannot be precisely determined by \nan MRI (33). CAT scans and MRIs can reveal thickening \nof the intestinal wall, but they cannot provide a diagnosis \nof the tissue unless a directed biopsy is requested (30). \nT ransvaginal echography has no value for diagnosing peri-\n\nRev Col Gastroenterol / 29 (2) 2014\n160\nCase report\nmore than 40% of the circumference of the rectum affected \nby the disease. J Minim Invasive Gynecol. 2008;15(3):280-5.\n17. Ong SY, Sim SY, Johnston M, Crowley P , Froomes P . \nEducation and imaging. Gastrointestinal: refractory ulcer -\native colitis complicated by colonic stricturing endometrio-\nsis. J Gastroenterol Hepatol. 2012;27(1):181.\n18. Samet JD, Horton KM, Fishman EK, Hruban RH. Colonic \nendometriosis mimicking colon cancer on a virtual colonos-\ncopy study: a potential pitfall in diagnosis. Case Rep Med. \n2009;2009:379578.\n19. 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