{"paper_id":"cdb7e656-b5e6-407c-b8b2-f2f4e707270a","body_text":"~ 4 ~ \nJournal of Case Reports and Scientific Images 2020; 2(1): 04-06 \n \n \nE-ISSN: 2708-0064 \nP-ISSN: 2708-0056 \nJCRSI 2020; 2(1): 04-06 \nwww.allcasereports.com  \nReceived: 05-04-2020 \nAccepted: 16-05-2020 \n \nAkogu Simon PO \nDepartment of Obstetrics and \nGynecology, Kogi State \nUniversity/Kogi State \nUniversity Teaching Hospital \nAnyigba, Kogi State Nigeria/ \nNeigbour Multicare Hospital \nand Women Welfare Centre, \nAnyigba, Nigeria \n \nAnthony I Emeka \nDepartment of Obstetrics and \nGynecology, Kogi State \nUniversity Teaching Hospital, \nAnyigba \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nAkogu Simon PO \nDepartment of Obstetrics and \nGynecology, Kogi State \nUniversity/Kogi State \nUniversity Teaching Hospital \nAnyigba, Kogi State Nigeria/ \nNeigbour Multicare Hospital \nand Women Welfare Centre, \nAnyigba, Nigeria \n \nEndometriosis: A diagnostic merry-go-round: A case \nreport \n \nAkogu Simon PO and Anthony I Emeka \n \nDOI: https://doi.org/10.22271/27080056.2020.v2.i1a.12  \n \nAbstract \nEndometriosis affects mainly menstruating women. We present a case of endometriosis complicated by \na tortuous diagnostic co urse and intestinal obstruction in a 28 year old nulliparous woman who had \nthree laparotomies on account of two wrong diagnosis in a resource limited setting. \n \nKeywords: Endometriosis. Misdiagnosis. Intestinal obstruction. Anyigba. Kogi \n \nIntroduction \nEndometriosis is the growth of endometrial tissue in other places outside the endometrium. It \nis a well-known and discussed cause of sub fertility. It is the cause of 15% of pelvic pain and \nseen in 21% of women being investigated for infertility.  It occurs in 5- 15 % of menstruating \nwomen while 20% of women with endometriosis are asymptomatic [1, 3, 5, 13, 14, 15]. \nGastrointestinal involvent in endometriosis has been reported in 3 -37% of menstruating \nwomen and the involvement of the ileaum causing intestinal obs truction has been found in 7-\n23% of cases of endometiosis [13]. \n \nCase Report \nMiss K.A presented at Neighbor Multicare Hospital and Women Welfare Centre Anyigba at \n28 years of age, she was a nulliparous secondary school graduate. She presented in October \n2018 with on and off pain for two years.  \nPain was colicky, sometimes severe in the night. It was located at the right lower quadrant of \nher abdomen and became generalized. She could not count the number of episodes but later \nbecame constant prior to presentation.  \nThere was non -projectile vomiting of any recently eaten solid meal. She could take only \nliquid diet. She had lost significant weight. She had gradual swelling of her lower abdomen. \nThere was change in her bowel habit from daily to once in five days with semi-solid stool. \nThe pain increased during her menses on some occasions. She also experienced pains before, \nduring and after her monthly menstruation in the last 3 years. Her menstrual cycle length was \n26-28 days with flow duration of 3-5 days. There was no menorhagia. \nShe was sexually active but had not used contraception before. \nShe had two previous surgeries on account of the recurrent pain: in October 2016, she had \nopen abdominal surgery for the pain said to be due to appendicitis and fibroid fol lowing an \nabdominal ultrasonogragpy. \nAt surgery no fibroid was found, the Appendix was removed. The pains returned less than 2 \nweeks post operation. She was in and out of the hospital and did not get relief.  \nIn April 2017, she was admitted in another hospi tal for surgery. The diagnosis was ovarian \ncyst and fibroid. At surgery, there was no fibroid but an ovarian cyst was removed. In less \nthan 3 weeks after discharge, the pain continued and became severe during menstruation.  \nShe went back to the hospital wh ere she had the last surgery and was counseled for another \nexploratory laparatomy which she declined and changed hospital to our facility. \nAt presentation, she was restless, not febrile to touch, not pale and anicteric. She was poorly \nnourished. \nThe thyroid and Breasts were normal. \nThe respiratory rate was 22 cycles per minutes, the lungs fields clear.  \nThe pulse rate was 94 beats per minutes, small volume and regular. The blood pressure was \n110/60mmHg. Only first and second heart sounds were heard, no murmurs or added sounds. \nAbdomen moved with respiration, was distend at the suprabupicarea. There was vague \ntenderness and a mass in the suprapubic region. \n\nJournal of Case Reports and Scientific Images http://www.allcasereports.com  \n \n~ 5 ~ \nThe vulval was normal, there was fullness in the vaginal \nfornices more on the right side; the cervix lo oked healthy \nbut mildly tender. \nRectal examination revealed good anal hygiene and normal \nsphincteric tone, no mass was palpable. \nA provisional diagnosis of Pelvic mass (Tubo –Ovarian) \ncausing partial intestinal obstruction was made. \nThe patient was admitted  into the ward and received \nimmediate supportive care. She was worked up for surgery. \nThe abdominal ultrasonography revealed “a mixed echo \nmass measuring 20 x 40cm extending from the right \nadnexum towards the midline with the right ovary showing \nmultiple n on septated cysts. The left ovary was enlarged \ntoo”.  \n \nShe had a third Exploratory Laparotomy. The findings at \nsurgery were: \n1. Previous midline laparotomy scar that healed by \nsecondary intention. \n2. Pelvic adhesions majorly on the right side of the pelvis \nmatting together the caecum, an enlarged right ovary, \npart of the terminal ileum (about 10cm),swollen part of \nright fallopian tube, uterus and an endometrioama on \nthe ovary and fallopian tube that formed part of the \ncomplex.. \n3. An enlarged left ovary that was 10cmx 25cm. \n4. Pussy thick exudates from both Ovaries. \n \nThe uterus, the caecum and ileum were carefully separated \nfrom the ovary by blunt dissection and the loops of ileum \nbound in adhesion were separated by blunt dissection. The \npockets of pus and the endometrioma were cleared. \nFurther adhesiolysis was performed and parts of both \novaries were resected for histology. The peritoneum was \nlavaged, mopped clean and closed with a drain left for \nabdominal drainage. \nThe abdomen was closed in layers. She was transfused o ne \nunit of blood intra operatively. Her immediate post \noperative condition was satisfactory.  \nThe ovarian tissue and endometroma –like tissues was sent \nfor histology.  \nThe patient`s post operative condition remained \nprogressively stable. The management incl uded close \nmonitoring, Supportive care, analgesia, antibiotherapy and \nfluid therapy. \nShe was discharge home on the 9th day post operation. \nShe was seen 4 weeks later, saw her menses once and was \ndoing well. Clinical examination yielded no abnormality. \nThe histology report: “specimens consist of 2 pieces of dark \nbrown tissue together measuring 3x3x2cm. Cut section \nshows grayish white surface. \nHistologic sections of the tissue shows ovarian stroma \ncontaining islands of endometrial glands and stroma, with \nareas of surrounding haemorrhage consistent with \nEndometriosis\" \nThe patient was placed on intramuscular Depoprovera \n150mg every 3 months for one year. This provided effective \nrelief of her pains.  Eleven months later, she expressed \nfertility desires and was ref erred to the out patients \ngynecology clinic of the Kogi state University Teaching \nhospital, Anyigba to further fertility care.  \n \nDiscussion \nEndometriosis is a condition with diverse presentations that \npresent a diagnostic challenge to many practitioners. I t \nshows a non-definite course in its pathogenesis.  \nThe clinical features of endometriosis include lower \nabdominal or pelvic pain, periumbilical pain, pelvic pain, \npain in the vagina and/or pain in the rectal area [1,  4]. \nThe pain is usually cyclic. In se vere cases the urinary \nbladder and bowels are affected. Endometriosis may also \npresent with dyspareunia, and dysmenorrhea. \nIt is believed that retrograde menstruation is cause of \nendometiosis . The backward flow of the menstrum carry \nendometrial tissue int o the peritoneal cavity as a form of \ntransplantation. This argument is supported by the fact that \nsuppressors of menstruation like oral contraceptive pills and \npregnancy tend to reduce the prevalence of endometriosis  [1, \n2, 3].  \nCoelomic metaplasia, surgical transplantation, genetic origin \nand auto immune pathogenesis have also been implicated in \nthe aetiology of endometriosis [9, 10, 11, 12].  \nEndometriosis is a complex syndrome largely due to an \ninflammatory event that is estrogen dependent. Among the \nSeveral factors associated with endometriosis include early \nmenarche which appear to increase the risk of endometriosis \nwhile current use of use of contraceptive and parity are \nassociated with decreased risk of endometriosis [3, 4]. \nThe management of endometr iosis can be expectant, \nmedical and/or surgical. Expectant management is for \npatients that are asymptomatic (mild endometriosis). Since \nthey have no symptoms, there is no need for any medical or \nsurgical interventions. Endometriosis is a progressive \ndisease; treating an asymptomatic patient has not been \nfound to prevent further progession [12].  \nMedical management include analgesia for pains, drugs like \ndanazol, a testosterone derivative and aromatase inhibitors \nlike anastrozole and letrozole [12]. Oral con traceptives, \nprogestogins and GnRH agonists are also useful and \neffective in the medical management of endometriosis [10, 11, \n12].  \nIn severe disease and with desires for fertility, the surgical \napproach is aimed at restoring the pelvic anatomy to as \nnormal as possible. The procedure involves excision or \ndestruction of the endometriotic tissues and adhesiolysis [12]. \nThe impact of advanced or severe (stage III and IV) \nendometriosis on fertility and the advances in diagnostic \ntechniques like ultrasonography and laparoscopy has \nheightened knowledge and depth management of \nendometriosis.  \nOur patient was a 28 year old nulliparous woman, a little \noutside the peak age of incidence of endometriosis which is \n30 – 45 year. Her case presented a diagnostic challenge \nleading to her case of endometriosis been diagnosed \nwrongly on two occasions; first as Appendicitis and uterine \nfibroid and secondly as ovarian cyst and uterine fibroid. It \nwas on the third occasion that a diagnosis of pelvic mass \ncausing intestinal obstruction was made which turned out to \nbe an endometriotic mass that trapped the terminal ileum in \nan adhesion complex causing intestinal obstruction. This \ndiagnostic failure and merry -go-round deserved to be \nreported to raise practitioners alertness in dealing  with such \npresentations. \nWhere specific diagnostic tools and/or expertise for \ndiagnosis are not available as in this case, wrong diagnosis \nis very common. The patient received two different wrong \ndiagnosis on two separate occasions within one and half \nyear.  \n\nJournal of Case Reports and Scientific Images http://www.allcasereports.com  \n \n~ 6 ~ \nThe first and second surgeries compounded and masked \nsome peculiar symptoms like cyclic abdominal pain \nconcurrent with menstrual flow.  \nEndometriosis can involve the bladder, intestine and other \npelvic structures.  In our patient the endometrioma and \nadhesion therein involved the right ovary, right fallopian \ntube, the terminal ileum, the caecum and the uterus causing \npartial intestinal obstruction. It was a stage III disease.  \nThe management include adhesiolysis, excision of \nendometrioma, analgesia and h ormonal therapy. Where \ncomplicated as in this case, specific steps are taken.  \nThe patient had adhesiolysis, excision of endometrioma and \na one year treatment with medroxy progesterone acetate \n(Depoprevera). She did well on this until she expressed \nfertility desire and was referred for further management.  \n \nConclusion \nThe diagnostic merry -go-round gone through by the patient \ncould be averted if there adequate diagnostic capacity and \nclinical acumen of clinicians. Efforts should be made to \nimprove on this fo r practitioners providing surgical services \nin resource limited settings. \n \nReferences \n1. David M. Luesley, Phillip N. Baker et al Obstetrics and \nGynecology. Evidenced based text for MRCOG, 544-8. \n2. Waddle PG, Hull MRG. Is endometriosis a disease? \nBailierie’sClin. Obstec. Gynecol. 1993; 7(4):673-85 \n3. Mahmood TA, Templetion A. 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