Colorectal Endometriosis Presenting as Proctalgia and Rectal Bleeding

Background: Endometriosis is defined as the seeding of endometrial glands and stroma at the extrauterine sites. These glands are mainly located in the pelvis but can also be found in the other parts of the body. Endometriosis is the one of the most common cause of chronic pelvic pain in women of reproductive age leading to debilitating symptoms. Here we report a case of 40 year old female with possible colorectal endometriosis. Case Report: A 40-year-old female with no co morbidities presented with multiple episodes of bloody stools for one day. As per patient, one day prior to admission, she reported proctalgia with menstrual periods. Few hours later, she had three episodes of bloody bowel moments (BM) which were bright red in color accompanied with blood clots which were similar to her menstruation. On arrival to ER at our facility her Hg was noted to be 11 gm/dl. She reports of having dysmenorrhea, dyspareunia, rectal and leg cramps since past year and was given a diagnosis of endometriosis by her gynecologist and was placed on medical therapy leuprolide depot monthly. She continued the treatment for 3 months with relief of her symptoms but self discontinued. On admission, vital signs were stable and physical exam was unremarkable. Rectal exam was grossly normal with no signs of active bleeding or hemorrhoids. Fecal occult blood testing was positive. Colonoscopy showed erythematous and beefy looking polypoid mass partially obstructing the lumen at 20 centimeters from the anal verge. Biopsy results were negative for any dysplasia or malignancy. Pt was discharged to follow up with gynecologist an outpatient for possible laparoscopy for the evaluation of endometriosis. Discussion: Endometriosis can present as debilitating symptoms in women of reproductive age. The pathogenesis of endometriosis is unclear and is thought to be due to retrograde menstruation. The most common sites for endometriosis are pelvis, sigmoid colon, abdominal cavity and rarely in thoracic and central nervous system. In majority of cases, laparoscopy is required but definitive diagnosis can be made only on histological evaluation of the specimen. The pre-operative diagnosis of colorectal endometriosis is difficult because of no definitive clinical and radiological findings that are suggestive or characteristic of this disease. Early recognition of symptoms suggestive of colorectal endometriosis should be made for more efficient therapeutic approach and better outcomes.Figure 1