A Diagnostic Conundrum - Small bowel obstruction from undiagnosed endometriosis following uterine perforation

A 42-year-old woman presented by private vehicle to a local, community-based hospital with recurrent episodes of nausea, vomiting, and abdominal pain over 2 years. Physical exam showed abdominal distention and tenderness, otherwise normal. Imaging was consistent with SBO, which was initially managed conservatively with NPO status and IV fluids. The patient's SBO was thought to be secondary to adhesions from her prior cholecystectomy. At her third hospitalization for these symptoms, she had a small bowel follow through that showed multiple dilated segments of small bowel in the abdomen & pelvis and a CT scan showing SBO with a transition point in the right lower quadrant and possible 2nd transition point in the mid pelvis ( Image 1 , Image 2 ). Image 1 Abdominal CT scans with contrast demonstrating a small bowel obstruction with a transition point in the right lower quadrant. Image 1 Image 2 Abdominal CT scans with contrast demonstrating a small bowel obstruction with a transition point in the right lower quadrant. Image 2 Abdominal CT scans with contrast demonstrating a small bowel obstruction with a transition point in the right lower quadrant. Abdominal CT scans with contrast demonstrating a small bowel obstruction with a transition point in the right lower quadrant. She was hemodynamically stable, and symptomatically improved with conservative management. However, given the recurrent nature of symptoms, she was scheduled for outpatient colonoscopy to assess for Crohn's disease. On colonoscopy, there was no evidence of Crohn's; however, a stricture was found in the terminal ileum with definitive narrowing of small bowel. The patient then underwent an elective, diagnostic laparoscopy with small bowel resection for recurrent SBO. Prior to laparoscopy, top differentials included possible adhesions, gallstone leakage from the prior cholecystectomy and Crohn's; endometriosis was low on the differential list. The patient's past medical history included Hashimoto's disease. Surgical history included laparoscopic cholecystectomy 15 years ago and a dilation & curettage 11 years ago complicated by uterine perforation, as recorded in her operative report by the obstetrician who performed her surgery. She received the D&C due to retained products of conception following childbirth two weeks prior. Following her D&C, she had secondary amenorrhea and infertility. She was never diagnosed with endometriosis nor had any endometriosis symptoms before or after her D&C. Her pathology from D&C showed large pieces of myometrium ( Image 3 ), which supports the presence of extrauterine endometrial tissue secondary to perforation. Her family, substance use, and psychosocial histories were non-contributory. Image 3 Pathology from D&C in 2012 with large pieces of myometrium. Image 3 Image 4 Photographed evidence of laparoscopic findings of tethering of ileum with endometriotic lesions at two separate locations. Image 4 Image 5 Pathology of endometrial tissue from biopsy - endometriosis full thickness (top) and endometriosis at high power (bottom). Image 5 Pathology from D&C in 2012 with large pieces of myometrium. Photographed evidence of laparoscopic findings of tethering of ileum with endometriotic lesions at two separate locations. Pathology of endometrial tissue from biopsy - endometriosis full thickness (top) and endometriosis at high power (bottom). The elective, diagnostic laparoscopy with small bowel resection was conducted by a colorectal surgeon. During the laparoscopy for SBO, there were multiple, dispersed endometriotic lesions scattered along the last 20 cm of the small bowel, with evidence of tethering that narrowed the small bowel ( Image 4 , video ). These lesions ended approximately 6–7 cm proximally from the ileocecal valve, consistent with the colonoscopy report showing definitive narrowing of the small bowel from a stricture. There was also a nodular lesion present on the appendix, but no other apparent abnormalities in the pelvis, abdomen, or diaphragm. There were at least two lesions that caused obstruction of the small bowel, leading to adhesion that was likely responsible for her SBO in two locations ( Image 4 ). The surgeon decided to perform a small bowel resection to address all portions of small bowel affected with endometriotic lesions, along with an appendectomy due to the abnormal nodule at the tip of the appendix. Primary small bowel anastomosis was done following the resection. The resected small bowel and appendix were sent to pathology, which showed “segment of benign small intestine with severe serosal endometriosis with extension into muscularis propria and very focal near-transmural involvement” ( Image 5 ). The nodule on the appendix was “benign with severe serosal endometriosis.” While there was suspicion of endometriosis causing her SBO from the endometriotic lesions found during laparoscopy, the pathology confirmed the presence of endometriosis in this patient without a prior diagnosis of endometriosis. Patient made an uneventful recovery after small bowel resection with resolving of SBO symptoms. In sum, a 42-year-old healthy female with a history of uterine perforation secondary to a D&C eleven years prior had recurrent SBO due to strictures of previously undiagnosed endometriosis.

Erina Horikawa – Writing the abstract, case presentation, discussion, literature review. Carmen Abbe – Writing the introduction, literature review. Luay Ailabouni – colorectal surgeon conducting the case. Brian Staley – Providing pathology pictures.

A fully informed written consent has been obtained and documented in paper for the patient that is the subject of this case report.

IRB approval.

None.

Luay Ailabouni.

Dilation and curettage is an important obstetric procedure used for therapeutic purposes for molar pregnancies, spontaneous and induced abortions, removal of uterine masses, or for diagnostic purposes such as obtaining an endometrial biopsy. This is a relatively safe procedure, however, complications can still occur, such as uterine perforation, cervical injury, incomplete procedure, and formation of intrauterine adhesions [ 6 ]. In our case, our patient suffered from both uterine perforation and intrauterine adhesions, resulting in Asherman syndrome and secondary amenorrhea. Uterine perforation occurs in anywhere between 0.3 and 5.1 % of D&C’s [ 7 ]. Risk factors for uterine perforation include cervical stenosis, distortion of the endocervical canal or the uterus, uterine malposition, pregnancy or lactation, and menopause. Immediate consequences of uterine rupture include hemorrhage, broad ligament hematoma, or hypotension. Postprocedural manifestations include severe or persistent pelvic or abdominal pain, abdominal distention, heavy or persistent vaginal bleeding, or injury to bladder, bowel, and other surrounding structures [ 7 ]. Small bowel obstruction after uterine perforation has not been well documented, we were only able to find one case of bowel obstruction following uterine perforation, reported over 10 years ago [ 8 ]. A review found that in documented cases, clinical presentation and time of presentation following uterine perforation varies significantly [ 9 ]. These cases further occurred after an induced abortion, not with a D&C indicated for retained products of conception. Our case is unique in that the complication of SBO occurred eleven years after the D&C, and as a result of endometriosis. Endometriosis has been a documented cause for SBO [ 10 , 11 ], however, endometriosis following a D&C procedure leading to SBO has not been documented. One of the dominant theories for the etiology of endometriosis, in which menstrual blood is implanted into the peritoneum, could explain the etiology of our patient having endometriosis following her D&C operation, with possible leakage of menstrual blood to nearby small bowel during perforation. Interestingly, our patient denied any classic endometriosis symptoms (chronic pelvic pain that worsens with menses) as she had amenorrhea secondary to Asherman syndrome, and further denied any non-menstrual related pelvic pain - suggesting an asymptomatic presentation of endometriosis other than the stricture resulting in SBO. Our case highlights the possibility of endometriosis due to previous uterine rupture as a cause for SBO in an otherwise healthy female of reproductive age without significant prior abdominal surgeries, inflammatory bowel disease, masses, malignancies, intussusception, or volvulus. Diagnostic studies were completed with a CT, and colonoscopy, and, despite the limitation of following up on a surgery 11 years ago, a definitive diagnosis was confirmed with laparoscopy and the pathology report. There is a continued need for appropriate documentation of surgical complications on patient charts as well as considering postoperative complications when other etiologies of SBO are less likely. The following is the supplementary data related to this article. Video S1 In this video you will see us carefully running the small bowel and identifying the areas of obstruction corresponding with the patient's CT scan. extraluminal implants are clearly visible. Video S1 In this video you will see us carefully running the small bowel and identifying the areas of obstruction corresponding with the patient's CT scan. extraluminal implants are clearly visible.

Endometriosis is a disease in which endometrial tissue proliferates outside of the uterine endometrium. An estimated 10–15 % of reproductive aged women are affected by endometriosis [ 1 ], which classically presents with irregular uterine bleeding, dysmenorrhea, pelvic pain, dyspareunia, and/or infertility. The most common anatomical locations of endometrial proliferation are the pelvic peritoneum, ovaries and rectovaginal space [ 2 ]. Although rarer, endometriosis has been found implanted on the bowel wall [ 3 ]. In people without a known diagnosis of endometriosis, this is low on the differential in cases of isolated GI complaints. The cause of endometriosis is still not well understood. The leading theories include retrograde menstruation, in which viable cells in the menstrual blood enter the peritoneal cavity, coelomic metaplasia, in which the parietal peritoneum epithelium itself differentiates into endometrial tissue, or lymphatic or vascular metastasis, in which endometrial cells are transmitted through lymphatic or hematologic systems [ 4 ]. Several factors are associated with increased risk of endometriosis, including early age of menarche, nulliparity, and menorrhagia [ 1 ]. The occurrence of endometriosis following surgeries in the pelvic space, such as dilation and curettage (D&C), are not commonly understood as factors increasing risk for the disease. Dilation and curettage is a diagnostic and therapeutic surgical procedure in which intrauterine tissue is removed using suction or sharp curettage. A known, albeit rare, complication of D&C is uterine perforation. Uterine perforation is the most common immediate complication following the procedure and is more common in pregnant women. Very few cases have explored the risk for new onset endometriosis following uterine perforation. We describe an interesting case in which a reproductive aged woman became amenorrheic following a D&C complicated by uterine perforation and presented to a community hospital with a small bowel obstruction (SBO) secondary to endometriosis eleven years following the procedure. Our case highlights the need for considering endometriosis as a differential diagnosis of small bowel obstruction and the importance of documenting surgical complications. This work has been reported in line with the SCARE criteria [ 5 ]. Ethical approval for this study (STUDY2022000102) was provided by the Providence IRB Committee per institutional protocol via IRB exempt determination by Providence Hospitals, Renton, WA on April 28th, 2022.

Not applicable.

None.