Uncommon Cause of Cyclical Bowel Symptoms: Recognizing Rectosigmoid Endometriosis in the Setting of Prior Cesarean Delivery

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Key Takeaways for Clinicians Endometriosis is a chronic estrogen-dependent inflammatory disorder that may involve extragenital organs, most commonly the rectosigmoid colon. Intestinal involvement often presents with nonspecific gastrointestinal complaints. Cesarean delivery as a risk factor for endometriosis: Women with prior cesarean delivery are 1.8x more likely to be diagnosed with endometriosis later compared to women who deliver vaginally.1 Iatrogenic implantation theory: During cesarean delivery, endometrial cells can be mechanically implanted, or seeded, into abdominal and pelvic tissue when the uterus is exposed •When endometrial cells are implanted into the surgical wound, they remain viable and proliferate under hormonal stimulation.2 Menstrual-associated symptoms: •79% of patients with endometriosis experienced cyclic pain associated with menstruation.3 •Endometrial implants undergo cyclical bleeding and inflammation, worsening symptoms during menses.3

of endoscopy in detecting endometriosis: •Initial colonoscopy may be nondiagnostic: serosa or muscular layers affected – may not be visible during routine endoscopy •Diagnostic delay: symptoms can overlap with other gastrointestinal conditions4 •Mean time from surgery to symptom onset: 3.7 years2 This represents a case of deep infiltrating rectosigmoid endometriosis with menstrual-related bowel symptoms and recurrent anemia despite initial nondiagnostic colonoscopy. Repeat colonoscopy and imaging lead to the diagnosis. Surgical resection with peritoneal endometrioma ablation was curative. 1. Andolf E, Thorsell M, Källén K. Caesarean section and risk for endometriosis: a prospective cohort study of Swedish registries. BJOG. 2013;120(9):1061-1065. doi:10.1111/1471 0528.12236 2. Nominato NS, Prates LFVS, Lauar I, Morais J, Maia L, Geber S. Caesarean section greatly increases risk of scar endometriosis. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2010;152(1):83-85. doi:10.1016/j.ejogrb.2010.05.001 3. Yıldırım D, Tatar C, Doğan O, et al. Post-cesarean scar endometriosis. tjod. 2018;15(1):33- 38. doi:10.4274/tjod.90922 4. Neamtu R, Dahma G, Mocanu AG, et al. Challenges in Diagnosis and Prevention of Iatrogenic Endometriosis as a Long-Term Surgical Complication after C-Section. IJERPH. 2022;19(5):2791. doi:10.3390/ijerph19052791 •Prior cesarean delivery is associated with increased risk of endometriosis •Patients often present to PCPs with anemia and nonspecific GI symptoms •Endoscopy may fail to detect endometriosis because lesions are often in the outer layers of the bowel wall •In the setting of prior C-section delivery, PCP should have an increased index of the suspicion for endometrial seeding after malignancy has been ruled out Figure 2: H&E stain demonstrating benign ectopic endometrial glands lined by simple columnar epithelium with surrounding endometrial stroma within the muscular wall of the sigmoid colon. Figure 1: Colonoscopy revealing 2-cm intraluminal bulge at the rectosigmoid junction with no muscoal abnormalities.