Small bowel obstruction secondary to ileal endometriosis: multisection computer tomography evaluation

Small bowel obstruction secondary to ileal endometriosis: multisection computer tomography evaluation C. L. Fernández-Rey, S. A. Álvarez-González, P. Díaz-Solís, A. Blanco-González and S. Costilla-García Services of Radiodiagnosis and General Surgery. Hospital Universitario Central de Asturias. Oviedo, Asturias. Spain 1130-0108/2009/101/12/872-874 REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS Copyright © 2009 ARÁN EDICIONES , S. L . REV ESP ENFERM DIG (Madrid) Vol. 101. N.° 12, pp. 872-874, 2009 Approximately 10 to 15% of pre-menopausal women are affected by endometriosis, which in rare cases can cause in - testinal obstruction (1). The presence of ectopic endometriotic tissue in the loops of the small bowel affects the serosa (visceral peritoneum) and muscularis propria, but never penetrates the mucosa (2). Fibrosis and secondary adhesions are the major causes of obstruction (2). Ileal involvement is uncommon and usually affects the terminal ileum within 10 cm of the ileocecal valve (3). Intestinal endometriosis should be suspected in cases of young nulliparous women with abdominal or pelvic pain (3,4). Imaging diagnosis is difficult. However, multisection computer tomography (CT) provides high spatial resolu - tion and multiplanar reformation images, which can be very demonstrative and characteristic. CASE REPORT We report the case of a 22-year-old woman without any significant prior medical history who presented with ab - dominal pain and high leukocytosis. A contrast-enhanced Fig. 1. MIP (Maximun Intensity Projection) of a coronal contrast-enhan - ced CT image showing the presence of two enhanced peritoneal nodu - les (*) and dilatation of the small bowel. Imagen coronal MIP (maximun intensity projection) de TC con contras - te que demuestra la presencia de dos nódulos peritoneales hipercap - tantes (*) y dilatación de asas de intestino delgado. Fig. 2. MIP from a coronal contrast-enhanced CT image showing a de - tailed endometriotic implant in the right ileo-cecal area (*) and a se - cond focus of endometriosis in the right annexial region (*). Imagen coronal MIP de TC con contraste que muestra con detalle un implante de endometriosis en el área íleo-cecal derecha (*) y un segun - do foco de endometriosis en la región anexial derecha (*). IPD 1595 FERNANDEZ REY:Maquetación 1 28/12/09 08:18 Página 872 multisection CT was performed, which revealed significant small-bowe l dilatationand multiple nodular contrast-enhanced le- sions located in the pelvis (Fig. 1). One of the lesions affected the right annexialregion while the remaininglesions were locat- ed in the visceral peritoneum involving the small bowel. The largest lesion measured approximate ly 3 cm in diameter and in- volved the appendiceal region and terminal ileum, this being the transitionpoint of the obstruction(Fig. 2). The diagnosis after CT examination was small-bowel obstruction secondary to intestinal endometriosis.Surgery confirmed the CT findings, iden- tifying multiple endometriotic implants in the serosa of the small bowel, especially at the level of the terminal ileum (Figs. 3 and 4). A segment of terminal ileum and the appendix were resected. Histopatho logical examinationof the resected specimen revealed endometriotic implants involving the appendix and terminalileum. REFERENCES 1. Ruiz-Tovar J, Pina Hernández JD, Lobo Martínez E, et al. Endometriosis intestinal. Rev Esp Enferm Dig 2007; 99(12): 732-3. 2. Martimbeau PW, Pratt JH, Gaffey TA. Small-bowel obstruction secondary to endometriosis. Mayo Clin Proc 1975; 50(5): 239-43. 3. Scarmato VJ, Levine MS, Herlinger H, Wickstrom M, Furth EE, Tureck RW. Ileal endometriosis: radiographic findings in five cases. Radiology 2000; 214: 509-12. 4. Woodward P J, Sohaey R, Mezzetti TP. Endometriosis: radiologic-pathologic correlation. Radiographics 2001; 21: 193-216. Fig. 3. Image demonstrating the existence of endometriotic peritoneal implants during the surgical intervention. Imagen que demuestra la existencia de implantes de endometriosis peritoneales durante la intervención quirúrgica. Fig. 4. Endometriotic implant in the visceral peritoneum, which enve- lops the small bowel with adhesions between loops. Foco de endometriosis en el peritoneo visceral que envuelve el intesti- no delgado con adherencias entre las asas. Vol. 101. N.° 12, 2009 SMALL BOWEL OBSTRUCTION SECONDARY TO ILEAL ENDOMETRIOSIS: 873 MULTISECTION COMPUTER TOMOGRAPHY EVALUATION REV ESP ENFERM DIG 2009; 101 (12): 872-874 IPD 1595 FERNANDEZ REY:Maquetación 1 28/12/09 08:18 Página 873