{"paper_id":"c3419a6c-5037-49a6-b73e-e5e76e2efb48","body_text":"Review began\n 01/15/2023 \nReview ended\n 01/16/2023 \nPublished\n 01/17/2023\n© Copyright \n2023\nQuintana-Rapatalo et al. This is an open\naccess article distributed under the terms of\nthe Creative Commons Attribution License\nCC-BY 4.0., which permits unrestricted use,\ndistribution, and reproduction in any\nmedium, provided the original author and\nsource are credited.\nCecal Endometriosis Presenting as Hematochezia\nin a Postmenopausal Female\nRoland J. Quintana-Rapatalo \n \n, \nDavong D. Phrathep \n \n, \nIvanna Ward \n \n, \nKevin D. Healey \n \n, \nStefan Anthony \n \n,\nMichael Herman \n1.\n College of Medicine, Florida International University, Herbert Wertheim College of Medicine, Miami, USA \n2.\n College\nof Osteopathic Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, USA \n3.\n College of Osteopathic\nMedicine, Philadelphia College of Osteopathic Medicine, Philadelphia, USA \n4.\n Gastroenterology, Borland Groover,\nJacksonville, USA\nCorresponding author: \nRoland J. Quintana-Rapatalo, \nrquin099@fiu.edu\nAbstract\nOur report highlights the diagnosis of cecal endometriosis as a unique cause of hematochezia in a\npostmenopausal female. Cecal endometriosis manifesting as intermittent hematochezia and abdominal pain\nis uncommon but requires prompt clinical diagnosis and management. We report a case of cecal\nendometriosis causing hematochezia and subsequent syncope, which prompted the patient’s admission to\nthe emergency department. In our patient, a diagnosis of cecal endometriosis was made after a colonoscopy,\nwith multiple biopsies confirming the presence of endometrial tissue embedded in the cecum. We aim to\nbring awareness of cecal endometriosis presenting as hematochezia in a postmenopausal woman with a\nhistory of abdominal pain. This case highlights intestinal endometriosis as a differential diagnosis to be\nconsidered in women, regardless of age, with intermittent hematochezia and abdominal pain.\nCategories:\n Obstetrics/Gynecology, Gastroenterology\nKeywords:\n cyclical abdominal pain, postmenopausal female, cecal endometriosis, endometriosis, hematochezia\nIntroduction\nEndometriosis is a condition where endometrial tissue is found outside of the uterus \n[1]\n. It affects 6-10% of\nwomen worldwide, who are commonly of reproductive age \n[2]\n. Common symptoms of endometriosis include\nmenorrhagia, dysmenorrhea, and dyspareunia although patients can remain asymptomatic \n[1]\n. One of the\nmost common sites of extragenital implantation is along the bowel and bowel-related implants can manifest\nas dyschezia or hematochezia \n[3]\n. Endometriosis causes right iliac fossa pain, especially during menstrual\nperiods because the endometrial-like tissue acts similar to the endometrium, where it thickens, breaks down,\nand bleeds with each menstrual cycle \n[3]\n. If endometrial tissue involves the bowels, it can cause intermittent\nabdominal pain, especially during menstrual periods \n[4]\n. In recent literature, endometriosis has been\ndocumented in postmenopausal females and has the potential to implant in the bowels. When endometrial\ntissue is implanted in the bowels, it usually occurs in the rectosigmoid and less frequently occurs in the\ncecum \n[4]\n. Cecal endometriosis can present as acute appendicitis, intussusception, volvulus, chronic\nabdominal/pelvic pain, or bowel obstruction \n[4]\n. However, in this report, we present a new clinical\npresentation of cecal endometriosis presenting as hematochezia in a postmenopausal female.\nCase Presentation\nA 51-year-old post-menopausal female reports to the emergency department for syncope and\ngastrointestinal bleeding. The patient’s husband immediately notified emergency medical services (EMS)\nwhen the patient was found on the floor with blood surrounding her. EMS described the patient’s blood as\ndark red. The patient reported two episodes of diarrhea the night of the incident but did not recall her\nsyncopal episode. She reported that the onset of the syncope and gastrointestinal bleeding only happened\none day prior to the incident and that the course and duration of her symptoms were intermittent. She had\nbeen suffering from intermittent hematochezia and reported severe abdominal pain during these episodes\nfor the past month. Her medical history revealed no medical conditions related to her complaints. There\nwere no recent changes in bowel habits or weight loss. She had no family history of colorectal cancer or\ninflammatory bowel disease. She denied tobacco and alcohol use. The patient had a previous colonoscopy a\nmonth prior to the episode, which revealed benign findings.\nOn admission, the patient was alert and oriented to person, place, time, and event. The patient appeared\nslightly pale and showed signs of apparent distress. Vital signs upon admission showed a blood pressure of\n117/65 mmHg, pulse of 67 per minute, temperature of 97.88 degrees Fahrenheit, respiratory rate of 18 per\nminute, and oxygen saturation of 99%. The patient denied nausea, vomiting, hematemesis, hemoptysis,\nfever, chills, and urinary abnormalities. A physical exam revealed a tender abdomen in the right lower\nquadrant with mild pain with palpation. Labs revealed low hemoglobin at 9.9 g/dL and low hematocrit at\n29.4%. The patient’s partial thromboplastin time was low at 22.8 seconds and glucose levels were high at 119\nmg/dL. The remainder of the patient’s lab values were stable. A pneumatic compression device was applied\n1\n2\n3\n2\n2\n4\n \n Open Access Case\nReport\n \nDOI:\n 10.7759/cureus.33886\nHow to cite this article\nQuintana-Rapatalo R J, Phrathep D D, Ward I, et al. (January 17, 2023) Cecal Endometriosis Presenting as Hematochezia in a Postmenopausal\nFemale. Cureus 15(1): e33886. \nDOI 10.7759/cureus.33886\n\nfor deep vein thrombosis prevention.\nThe patient underwent CT angiography of the abdomen and pelvis, which revealed no evidence of an active\ngastrointestinal bleed. There was no evidence of significant stenosis, dissection, or aneurysm. The patient\nwas advised about her current situation, and she was discharged with scheduled follow-up visits with\ngastroenterology. A follow-up colonoscopy revealed an erythematous nodule embedded in the cecum\n(Figure \n1\n).\nFIGURE\n 1: Colonoscopy image of an erythematous nodule embedded in\nthe cecum\nMultiple biopsies were taken from the cecum. The pathologic examination showed ectopic endometrial\nglands in the cecum. There was no microscopic evidence of any other pathologies. Given the absence of\nother possible etiologies, we attribute her hematochezia to cecal endometriosis. The patient was\nrecommended to follow up with an outpatient gynecologist for a consultation.\nDiscussion\nEndometriosis is defined as an ectopic proliferation of endometrial tissue outside the uterine cavity \n[5]\n. It is\nfairly common in women of childbearing age. Bowel involvement in endometriosis is uncommon and\nusually localized in the rectosigmoid and less frequently in the cecum. Among instances of bowel\nendometriosis, the cecum, along with the appendix and ileocecal junction, were found to be the third most\ncommon site of implantation \n[5]\n. To date, there have been two documented findings of cecal endometriosis\nin a postmenopausal female but none that have presented with hematochezia \n[6,7]\n. The prevalence of\nendometriosis in postmenopausal females is reported to be between 2% and 5% \n[8]\n. In the hypoestrogenic\nstate of menopause, symptoms of endometriosis are expected to decrease due to the atrophy of\nendometriotic lesions. However, there have been descriptions of recurrent endometriotic lesions presenting\nin a postmenopausal female \n[9]\n. Instances of recurrence are theorized to be due to exogenous estrogen use\nor peripherally produced estrogen causing reactivation of the lesions. De novo mutations have also been\npreviously described. As the patient was no longer menstruating, metaplasia of the parietal peritoneum is\nmore likely an explanation.\nThe underlying pathophysiology of this patient’s condition is likely multifactorial and may be explained by\nhistorical etiological hypotheses of endometriosis, which are mostly found to be in women of reproductive\nage. Consistent with the retrograde menstruation hypothesis, a clockwise flow of peritoneal fluid containing\nrefluxed endometrium can deposit on the cecum \n[10]\n. Additionally, the parietal peritoneum could undergo\ncoelomic metaplasia to endometrial-like cells especially due to the close proximity of the bowel to the\nperitoneum or right abdominal side wall \n[10]\n. Regardless of the means of deposition, the infiltrating\nendometrial tissue then can grow into the intestines, which is what ultimately caused blood to begin\npresenting within the stool, which has been a notable finding in earlier reports \n[11]\n.\n2023 Quintana-Rapatalo et al. Cureus 15(1): e33886. DOI 10.7759/cureus.33886\n2\n of \n3\n\nThe diagnosis of endometriosis, especially cecal endometriosis in an emergent setting, is difficult clinically\n[4]\n. Current literature comments on cecal endometriosis presenting as acute appendicitis, intussusception,\nCrohn's disease, volvulus, chronic abdominal/pelvic pain, tubo-ovarian abscess, cecal diverticulitis, ileocecal\ntuberculosis, or bowel obstruction \n[4]\n. Our case highlights the need for clinical suspicion of endometriosis as\na differential diagnosis to be considered in women of any age who are presenting with intermittent\nhematochezia and abdominal pain. As the patient had cyclical abdominal pain, it also highlights the\nimportance of screening questions related to menstrual irregularities while obtaining the history and\nphysical. Our case highlights cecal endometriosis as a cause of intermittent hematochezia and severe\nabdominal pain in a postmenopausal female.\nTypically, surgical removal of the endometrium tissue via laparoscopy or laparotomy from the bowels is the\nmost common treatment. Depending on the location, severity, and size of bowel involvement, patients can\nundergo segmental bowel resection, rectal shaving, or disc resection for the treatment of bowel\nendometriosis. A right hemicolectomy is a procedure that can be performed by laparotomy and has been\nused in the current literature for the treatment of cecal endometriosis \n[4]\n. For cecal endometriosis, surgery\nmay be considered to avoid complications like additional bleeding, perforation, bowel obstruction, and\nmalignant tumor formation \n[4]\n. It is important to consult with a gynecologist to determine the appropriate\nsurgery that needs to be performed. Our patient was consulted by gastroenterology for the presentation of\nhematochezia and then was referred to a gynecologist for consultation and treatment recommendations.\nConclusions\nEndometriosis is often a painful disorder in which endometrial tissue grows outside of the uterus.\nEndometriosis most commonly involves the ovaries, fallopian tubes, and pelvis lining. Rarely, endometrial\ntissue may be found beyond areas where the pelvic organs reside. Bowel involvement in endometriosis is\nuncommon, but when it occurs, it is usually localized to the rectosigmoid and less frequently in the cecum.\nThis report is that of a 51-year-old female who presented with a history of intermittent hematochezia and\nsevere abdominal pain for a month. Our case highlights cecal endometriosis as a differential diagnosis to be\nconsidered in women, regardless of age, with intermittent hematochezia. Current literature comments on\ncecal endometriosis presenting as acute appendicitis, intussusception, volvulus, chronic abdominal/pelvic\npain, or bowel obstruction. However, our report identifies an additional clinical presentation of cecal\nendometriosis presenting as hematochezia. A high index of suspicion is required for diagnosis, especially if\nthe woman has a history of cyclical abdominal pain. We urge further research to be completed to identify\nadditional unique clinical presentations of cecal endometriosis.\nAdditional Information\nDisclosures\nHuman subjects:\n Consent was obtained or waived by all participants in this study. \nConflicts of interest:\n In\ncompliance with the ICMJE uniform disclosure form, all authors declare the following: \nPayment/services\ninfo:\n All authors have declared that no financial support was received from any organization for the\nsubmitted work. \nFinancial relationships:\n All authors have declared that they have no financial\nrelationships at present or within the previous three years with any organizations that might have an\ninterest in the submitted work. \nOther relationships:\n All authors have declared that there are no other\nrelationships or activities that could appear to have influenced the submitted work.\nReferences\n1\n. \nPeiris AN, Chaljub E, Medlock D: \nEndometriosis\n. 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J Minim Invasive Gynecol. 2019, 26:814-5.\n10.1016/j.jmig.2018.11.001\n7\n. \nBailey AP, Schutt AK, Modesitt SC: \nFlorid endometriosis in a postmenopausal woman\n. Fertil Steril. 2010,\n94:2769.e1-4. \n10.1016/j.fertnstert.2010.04.044\n8\n. \nHanáček Jiří, Drahoňovský Jan, Heřman Hynek, et al.: \nEndometriosis in postmenopause\n. Ceska Gynekol.\n2022, 87:427-31. \n10.48095/cccg2022427\n9\n. \nWeber ML, Germeyer A: \nEndometriosis and menopause [Article in German]\n. Ther Umsch. 2021, 78:441-6.\n10.1024/0040-5930/a001295\n10\n. \nYong PJ, Bedaiwy MA, Alotaibi F, Anglesio MS: \nPathogenesis of bowel endometriosis\n. Best Pract Res Clin\nObstet Gynaecol. 2021, 71:2-13. \n10.1016/j.bpobgyn.2020.05.009\n11\n. \nCampagnacci R, Perretta S, Guerrieri M, Paganini AM, De Sanctis A, Ciavattini A, Lezoche E: \nLaparoscopic\ncolorectal resection for endometriosis\n. Surg Endosc. 2005, 19:662-4. \n10.1007/s00464-004-8710-7\n2023 Quintana-Rapatalo et al. Cureus 15(1): e33886. DOI 10.7759/cureus.33886\n3\n of \n3","source_license":"CC0","license_restricted":false}