SMALL BOWEL ENDOMETRIOSIS

Introduction: The gastrointestinal tract is the most common site of extrapelvic endometriosis, usually in the rectosigmoid region. Small bowel involvement is very uncommon. Although often asymptomatic, affected women can present with crampy abdominal pain, obstructive symptoms, or anorexia and weight loss. We describe a case of small bowel endometriosis that presented as an apparent cyclical vomiting syndrome. Case Presentation: A 30-year old woman presented with the acute onset of nausea and bilious vomiting along with periumbilical and right upper quadrant abdominal pain and loose nonbloody stool. Over the previous year, she had experienced similar episodes approximately every 3 months, with no notable association with her menstrual cycles. Each episode lasted around 4 or 5 days and resolved spontaneously. She had no history of abdominal surgery. Extensive radiologic and endoscopic evaluation prior to this episode was non-diagnostic. CT scan of the abdomen and pelvis during this episode revealed fluid-filled small bowel loops with mural thickening. A small bowel series revealed a single fixed dilated loop of ileum near the terminal ileum (TI) with irregularity of the TI. At colonoscopy, intubation of the TI revealed narrowing with edema and erythema at 8 cm of insertion, beyond which intubation was impossible. She subsequently underwent laparoscopy, which revealed a dilated distal small bowel with hemorrhagic purplish serosal plaques in a scarred narrow segment. Pelvic and rectosigmoid implants were also noted. The operation was converted to an open laparotomy. A short segment of distal small bowel and ascending colon was removed and an ileocolonic anastomosis was performed. She recovered uneventfully from the surgery. Histopathology confirmed the invasion of endometrial glands and stroma into the muscularis propria of the small bowel, consistent with small bowel endometriosis. As an outpatient she received one dose of intramuscular leuprolide and was subsequently lost to follow up. Discussion: Small bowel endometriosis is an uncommon cause of intermittent small bowel obstruction, and rarely presents as periodic episodes of vomiting. Affected women may not report any correlation of their symptoms with their menses, therefore the diagnosis should not be ruled out by the absence of this historical point.