S2263 A Case of Small Bowel Endometriosis

INTRODUCTION: Intestinal endometriosis is an important consideration in females who present with gastrointestinal complaints. Endometriosis of the intestines can involve the large or small bowel, and presenting symptoms can vary including asymptomatic, bloating, diarrhea, or even bowel obstruction. Often misdiagnosed as inflammatory bowel disease or irritable bowel syndrome, identifying intestinal endometriosis can avoid unnecessary, costly treatments and improve quality of life. CASE DESCRIPTION/METHODS: A 36 year-old female presented to the emergency department with nausea, vomiting, and abdominal pain. CT imaging demonstrated wall thickening involving the distal small bowel, including the terminal ileum. Colonoscopy demonstrated normal colonic mucosa with mild erythema and edema of the terminal ileum. Biopsies of the terminal ileum returned as lymphoid aggregates. The patient was treated supportively for partial small bowel obstruction and discharged home with close follow up in gastroenterology clinic. After further discussion in the outpatient setting, she was started on biologic and immunomodulator therapy for suspected small bowel Crohn's disease. Follow up small bowel imaging after several months of therapy demonstrated worsening small bowel inflammation with possible fistula formation. Due to persistent, intermittent symptoms, the patient was referred to surgery for further evaluation. She subsequently underwent ileocecal resection with pathology demonstrating endometriosis. DISCUSSION: Females with bowel endometriosis commonly present with classic symptoms of endometriosis along with varying gastrointestinal symptoms including rectal bleeding, constipation, bloating, painful defecation, and even bowel obstruction. Although the rectum is the site more commonly involved, other areas of the intestine including the small bowel can be involved. In our case, the patient noted gastrointestinal symptoms which were more severe during menstruation periods. Although inflammatory bowel disease can present similarly, the differential should remain broad and a thorough evaluation should be performed in order to best manage the patient. Follow small bowel resection, the patient has been taken off of biologic and immunomodulator therapy and is doing well with close gynecologic follow up.