{"paper_id":"d0d5a29f-d2f3-466d-bbc9-a7791d289afb","body_text":"IJCRI 2011;2(9):12-16.                                                                                                                                    Arachchi et al.  12   \nwww.ijcasereportsandimages.com  \nIJCRI – International Journal of Case Reports and Images, Vol. 2, No. 9, September 2011. ISSN – [0976-3198]  \n \n  \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nABSTRACT  \n \nIntroduction: Endometriosis is a common \ncondition in young females. It can affect \nvarious organs and present in a number of \nways. Intestinal endometriosis can cause \nserious complications including small bowel \nobstruction.  Case report: We report the case of \na 39-year-old female who had repeated \npresentations to the emergency department \nwith cyclical right iliac fossa pain caused by \nintestinal endometriosis that evolved to an \nextent where significant bowel stricturing and \nadhesion formation occurred causing an acute \nsmall bowel obstruction requiring a right \nhemicolectomy. Conclusion: Intestinal \nEndometriosis is an important differential \ndiagnosis for abdominal pain in females of \nreproductive age group. \n \nKeywords: Intestine, Endom etriosis, Bowel \nobstruction, Appendix, Intussusception \n \n*********  \n \nArachchi A, Vasudevan A. A case of small bowel \nobstruction secondary to intestinal endometriosis. \nInternational Journal of Case Reports and Images \n2011;2(9):12-16.\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 \ndoi:10.5348/ijcri-2011-09-49-CR-4 \n \n \n \nINTRODUCTION  \n \nEndometriosis is defined as the presence of ectopic  \nendometrial tissue outside the lining of the uterin e \ncavity. It is a considerably common disease and is \nestimated to affect between 4 and 50% females of \nreproductive age group [1]. The pelvic organs are m ost \ncommonly affected but the bowel, urinary tract and \nextra-abdominal organs can also be involved [2]. \nIntestinal endometriosis occurs in 3 to 37% cases a nd \nis usually asymptomatic [3, 4]. The rectosigmoid is  the \nmost commonly affected region of the gut, being \ninvolved in about 70% cases. Involvement of the sma ll \nbowel is much less common, occurring in only 1 to 7 % \ncases, and is usually confined to the distal ileum [5]. \nComplete bowel lumen obstruction occurs in less tha n \n1% of cases [5].  We report the case of a female wi th \nintestinal endometriosis which went undiagnosed unt il \nher third presentation to the emergency department \nwhen she presented with an acute small bowel \nobstruction. Involvement of the ileum, cecum and \nascending colon resulted in a small bowel resection  \nand right hemicolectomy. \n \n \nCASE REPORT  \n \nA 39-year-old nulliparous female presented to our \nEmergency Department on three occasions over a \nperiod of three weeks. On the first two presentatio ns \nthe patient had cramping generalized abdominal pain  \nassociated with nausea. She suffered from \ndysmenorrhoea and menorrhagia but described the \npain to be worse and more generalized than her \nregular menstrual pain. She did not have any other \nnotable symptoms particularly no gynaecological \nsymptoms. The patient was previously well with no \npast medical history of note, including no previous  \nA case of small bowel obstruction secondary to \nintestinal endometriosis  \n \nAsiri Arachchi, Abhinav Vasudevan \n \nCASE REPORT                                      OPEN ACCESS  \nAsiri Arachchi 1, Abhinav Vasudevan 1 \nAffiliations:  1Australia. \nCorresponding Author:  Asiri Arachchi, Ph: \n+61404235873; Email: asiriarachchi@gmail.com \n \n \nReceived: 10 March 2011 \nAccepted: 22 May 2011 \nPublished: 30 September 2011 \n \n\nIJCRI 2011;2(9):12-16.                                                                                                                                    Arachchi et al.  13   \nwww.ijcasereportsandimages.com  \nIJCRI – International Journal of Case Reports and Images, Vol. 2, No. 9, September 2011. ISSN – [0976-3198]  \n \nabdominal surgery. She was not on the oral \ncontraceptive pill. \nInvestigations included routine bloods tests, \nincluding inflammatory markers, which were normal \non both previous occasions. Abdominal X-ray showed \nfecal loading, particularly in the ascending colon but \nno evidence of bowel obstruction was seen (Figure 1). A \npelvic ultrasonogram (USG) was conducted on the \nsecond presentation which was normal. The patient’s  \npain had improved with simple analgesia on both \noccasions and she was discharged home from the \nemergency department on simple analgesia and oral \naperients, with a presumed diagnosis of constipation. \nOn the third occasion the patient presented with \nworsening of the cramping abdominal pain associated  \nwith nausea and vomiting. The pain was more severe \nthan on previous occasions and localized to the \nepigastric region and left upper quadrant. She was \nvomiting food particles and not passing gas. Her la st \nmenstrual period was one week prior to presentation. \nOn examination she was afebrile but tachycardic \nwith a heart rate of 104/min, blood pressure of 115 /60 \nmmHg and oxygen saturation of 97% on room air. On \nauscultation her heart sounds were normal and lungs  \nwere clear. Abdominal examination showed a \ndistended abdomen with generalized tenderness which  \nwas worse in the epigastrium, without guarding or \nrebound tenderness. No masses were felt. Bowel \nsounds were present. Rectal examination found an \nempty rectum. Vaginal examination showed no \nevidence of adnexal tenderness nor was pain elicited  \n \n \n \n \nFigure 1:  Chest X-ray was normal with no air under  the \ndiaphragm. Multiple fluid levels were noted on the erect \nabdominal film. \nwith palpation at the fornices. \nThe patients bloods showed a raised C-reactive \nprotein of 62 mg/L (normal <3 mg/L) and a \nhemoglobin that had dropped from 15.4 g/dL to 11.7 \ng/dL in the last one week. Peripheral blood smear a nd \nand routine blood tests were normal. \n An abdominal computed tomography (CT) scan \nwith oral and intravenous contrast was performed \nwhich confirmed a small bowel obstruction possibly \nsecondary to adhesions (Figure 2 A, B). There was \nbowel dilatation in the mid to distal small bowel w here \nthe bowel was 5.2 cm in diameter. No evidence of an y \nobstructing mass was noted and no lymphadenopathy \nwas visualized. The transition point of the obstruc tion \nwas not obvious. The rest of the study was normal i n \nappearance. \n \nThe provisional diagnosis by the surgical team was \na small bowel obstruction but the cause was not cle ar \nand acute appendicitis could not be excluded. The \ndecision was made to perform an emergency \ndiagnostic laparoscopy. \nOn laparoscopy the major abnormality was \nadherence of the distal small bowel to the pelvis. The \noperation was converted to a lower midline \nlaparotomy. There was a stenotic and fibrosed termi nal \nileum and cecum which were adhering to the sigmoid \ncolon, right ovary and uterus due to a brown nodule . \nMost of the cecum and some of the mesenteric fat wa s \nnoted to be hemorrhagic and fibrotic with adhesions . \nThere were multiple inflamed lymph nodes in the \nmesentery of the bowel. Within the cecum there was a \nprotrusion of mucosa about 20x12x9 mm. It was \nunclear whether this picture was due to a neoplasm,  \ninflammatory bowel disease or endometriosis.  The \nileum and cecum were dissected of the pelvic \nstructures and the terminal ileum and cecum were \ndivided. Twenty cm of the terminal ileum and 15 cm of \nthe right colon were resected, adhesions were divid ed \nand a primary anastamosis was performed. \n Histological examination of the resected ileum \nshowed focal areas of superficial mucosal ulceratio n \nwith destruction of glands and a neutrophilic infil trate \n(Figure 3 A, B). Granulomas were not seen. Sections  \ntaken from the strictured ileum showed the presence  of \nendometrial glands and stroma on the serosal surfac e \nof the bowel, extending into the outer  half of  th e   \nmuscularis propria. There was associated fibrosis, \nscarring and distortion of the wall and the overlyi ng \nmucosa. There was no evidence of dysplasia or \nmalignancy. The area of polypoidal mucosa within th e \ncecum appeared to be the mouth of the appendix \nwhich was also associated with endometriosis, fibro sis \nand scarring and had completely intussuscepted into  \nthe cecum. The diagnosis made was endometriosis \nwith associated inflammation and stricture formatio n \ninvolving the distal ileum, appendix, cecum, ascend ing \ncolon, omental fat and associated lymph nodes. Post -\nlaparotomy our patient made an unremarkable \nrecovery and was discharged home. She was followed \nup in  the surgical   outpatients  clinic  after  two  weeks  \n\nIJCRI 2011;2(9):12-16.                                                                                                                                    Arachchi et al.  14   \nwww.ijcasereportsandimages.com  \nIJCRI – International Journal of Case Reports and Images, Vol. 2, No. 9, September 2011. ISSN – [0976-3198]  \n \n \n \n \nFigure 2: A, B) Abdominal CT with IV and oral contr ast: \nshows bowel dilatation in the mid to distal small bowel where \nthe bowel was 5.2 cm in diameter. \n \n \n \nwhere no further complications were noted. \n \n \nDISCUSSION \n \n Endometriosis of the intestine is rare and \nobstruction due to endometriosis is even less common, \n \n \n \n \nFigure 3: A, B) Histopathology of the small bowel showing an \narea affected by endometriosis. \n \n \n \n \nwith an incidence rate of 0.8% [6]. The majority of  \ncases of intestinal endometriosis involve \ntherectosigmoid, which accounts for 70 to 95% of \ncases, with small intestinal, cecal and appendiceal  \ninvolvement occurring in decreasing frequency [7, 8 ]. \nOur case highlights some important aspects of \nintestinal endometriosis: initial presentation with  \nvague abdominal symptoms which was followed by an \nacute presentation of small bowel obstruction and \nappendiceal intussusception due to endometriosis \nwhich was most likely a red herring in our case. \nPatients with intestinal endometriosis may remain \nasymptomatic or can present to medical attention wi th \nsymptoms including constipation and diarrhea, \nindigestion, cramping abdominal pain, nausea, \nbloating or abdominal mass [4, 5]. These symptoms \nare classically cyclical and closely related to the  first \nday of the menstrual cycle but can be unrelated to \nperiods [8]. In our patient symptoms were occurring  \nperiodically, but the symptoms were vague and \nradiographic findings lacked specificity so the \ndiagnosis remained elusive on the first two \npresentations. This is similar to reported cases in  the \nA \nA \nB \nB \n\nIJCRI 2011;2(9):12-16.                                                                                                                                    Arachchi et al.  15   \nwww.ijcasereportsandimages.com  \nIJCRI – International Journal of Case Reports and Images, Vol. 2, No. 9, September 2011. ISSN – [0976-3198]  \n \nliterature, where the lack of specific features mad e \nearly diagnosis of the condition near impossible. \nAcute, partial or chronic intestinal obstruction ca n \nalso occur as a result of intestinal endometriosis,  \nalthough it is rare, with a reported incidence rate  of \n0.8% [6]. Obstruction of the small bowel most \ncommonly occurs in the ileum [7]. The proposed \nmechanism is proliferation of endometriotic tissue and \nreactive fibroplasia within the muscularis propria and \nsubmucosal layers which causes gradual obstruction of \nthe intestinal lumen [9]. In cases where previous \nsurgery has been performed, kinking and fibrosis of  \nthe bowel wall related to the procedure may also be  the \ncause of obstruction [6]. In our case no previous \nabdominal procedures had been performed on the \npatient. The patient’s two prior presentations to t he \nemergency department may have been due to a partial  \nbowel obstruction from stricturing in the terminal \nileum which was demonstrated on pathological \nfindings. Complete bowel obstruction may then have \nresulted from kinking of the small bowel when it wa s \nadherent to the pelvic structures and this resulted  in \nthe final acute presentation.  \nA histological finding of note in our case is the \nfinding of a polypoid mass that was actually an \nintussuscepted appendix in the cecum (Figure 3), \nwhich is a documented complication of endometriosis  \nof the appendix. It is an extremely rare phenomenon  \n[10] but worth noting as a differential diagnosis f or a \nneoplasm since malignancy occurs in 0.7 to 1% cases  of \nintestinal endometriosis [11]. Intussusception of t he \nappendix is believed to occur as a result of endome trial \ntissue infiltrating the muscularis propria and lead ing \nto hypertrophy and hyperplasia. Strong peristaltic \ncontractions due to the hypertrophic segment of the  \nappendix can then force the appendix into the cecal  \nlumen and cause intussusception of the appendix [10 ]. \nIn our case the entire appendix had inverted into t he \ncecum. An intussuscepted appendix may remain \nasymptomatic or can cause acute abdominal pain, a \npalpable mass in the lower abdomen or non-specific \ngastrointestinal symptoms like vomiting and diarrhe a \n[12, 13]. In our case it was most likely an inciden tal \nfinding. \n \n \nCONCLUSION \n \n \nIntestinal endometriosis is uncommon and often \npresents with nonspecific gastrointestinal symptoms  \nbut can also present as acute bowel obstruction. \nRadiological findings can be non-specific and \nlaparoscopy or laparotomy with resection of affecte d \nareas for biopsy remains the mainstay of diagnosis.  \nThe diagnosis should be suspected in young \nnulliparous patients with abdominal pain and clinic al \nfeatures of intestinal obstruction.   \n \n \n*********  \nAuthor Contributions  \nAsiri Arachchi – Substantial contributions to \nconception and design, Acquisition of data, Analysi s \nand interpretation of data, Drafting the article, \nRevising it critically for important intellectual c ontent, \nFinal approval of the version to be published \nAbhinav Vasudevan – Substantial contributions to \nconception and design, Acquisition of data, Analysi s \nand interpretation of data, Drafting the article, \nRevising it critically for important intellectual c ontent, \nFinal approval of the version to be published \n \nGuarantor \n \nThe corresponding author is the guarantor of \nsubmission. \n \nConflict of Interest \n \nAuthors declare no conflict of interest. \n \nCopyright \n \n© Asiri Arachchi et al. 2011; This article is distr ibuted \nunder the terms of Creative Commons attribution 3.0  \nLicense which permits unrestricted use, distributio n \nand reproduction in any means provided the original  \nauthors and original publisher are properly credite d. \n[Please see www.ijcasereportsandimages.com \n/copyright-policy.php for more information.] \n \n \nREFERENCES  \n \n1. Olive DL, Schwartz LB. Endometriosis. N Engl J \nMed. 1993;328:1759-69. \n2. Ranney B. The prevention, inhibition, palliation and \ntreatment of endometriosis. Am J of Obs and \nGynec. 1975;123:778-85. \n3. Macafee CH, Greer HL. Intestinal endometriosis. A \nreport of 29 cases and a survey of the literature. J \nObstet Gynaecol Br Emp. 1960;67:539-55. \n4. Yantiss RK, Clement PB, Young RH. Endometriosis \nof the intestinal tract: a study of 44 cases of a \ndisease that may cause diverse challenges in clinic al \nand pathologic evaluation. Am J Surg Pathol. \n2001;25:445-54. \n5. De Ceglie A, Bilardi C, Blanchi S, et al. Acute sma ll \nbowel obstruction caused by endometriosis: A case \nreport and review of the literature. World J \nGastroenterol 2008;14(21):3430-4. \n6. Martimbeau PW, Pratt JH, Gaffey TA. Small-bowel \nobstruction secondary to endometriosis. Mayo Clin \nProc. 1975;50:239-43. \n7. Mussa FF, Younes Z, Tihan T, Lacy BE. Anasarca \nand small bowel obstruction secondary to \nendometriosis. J Clin Gastroenterol. 2001;32:167-\n171. \n8. Townell, N H, Vanderwalt, J D. Intestinal \nendometriosis: diagnosis and management. Br J \nSurg. 1984;71:629-30. \n9. LiVolsi VA, Perzin KH. Endometriosis of the small \nintestine, producing small intestinal obstruction o r \nsimulating neoplasm. Dig Dis. 1974;19:100–8. \n10. Samia I, Lidder S, Mohamid W, Carter M, \nThompson H. Intussusception of the appendix \n\nIJCRI 2011;2(9):12-16.                                                                                                                                    Arachchi et al.  16   \nwww.ijcasereportsandimages.com  \nIJCRI – International Journal of Case Reports and Images, Vol. 2, No. 9, September 2011. ISSN – [0976-3198]  \n \nsecondary to endometriosis: a case report. J Med \nCase Reports. 2008;2:12. \n11. Chen KT. Endometrioid adenocarcinoma arising \nfrom colonic endometriosis mimicking primary \ncolonic carcinoma. Int J Gynecol Pathol. \n2002;21:285-8. \n12. Chen KT. Endometrioid adenocarcinoma arising \nfrom colonic endometriosis mimicking primary \ncolonic carcinoma. Int J Gynecol Pathol. \n2002;21:285-288. \n13. Mann WJ, Fromowitz F, Saychek T, Madariaga JR, \nChalas E. Endometriosis associated with \nappendiceal intussusception: a report of two cases.  \nJ Reprod Med. 1984;29:625–9.","source_license":"CC0","license_restricted":false}