Enterovesical fistula and intestinal obstruction by ileal endometriosis

Endometriotic foci, when implanted in the digestive tube would produce, according to the novel “neurological hypothe - sis”, progressive infiltration into the muscularis propia and sub- mucosa along the nerve fibers (3). The mucosa is affected only rarely so the endoscopic study with biopsy is usually unspecific and this is one of the diagnostic difficulties. If we add that the symptoms are not typical for gynecological endometriosis, the problem of diagnosis is even greater (4). When affected terminal ileum, stenosis occurs suggesting Crohn’s disease, as in our case, being this the most important aspect since both diseases have different treatments. There are numerous reported cases of ileal endometriosis mimicking Crohn and eight cases where both diseases coexist (5). The multislice CT can make suspect this entity (2,6), but possibly the only thing conclusive is the exploratory laparoscopy and the diagnosis is still given by the histological study (7). Our patient began with intestinal obstruction and enteroves - ical fistula. There have been at least 14 reported cases of intes - tinal perforation by endometriosis and 3 fistulation but have not found a case like the one presented (5,8,9). Why does this hap - pen? It is noteworthy that in most of the few reported cases the patients were pregnant, were in the postpartum period, in oral contraceptives or other hormonal therapy to cure the activity of endometriotic foci. This hormonal influence may produce an initial decidualization and endometrial tissue growth, making it more infiltrating in depth, coming to pass the mucous not only producing stenosis but perforation or fistulation (3,8). V ol. 105, N.º 8, 2013 LETTERS TO THE EDITOR 505 Rev esp enfeRm Dig 2013; 105 (8): 504-506 The widely recommended treatment in all cases of intestinal endometriosis is surgical resection. When an implant is appreci- ated by chance, might be consider performing a simple nodulec- tomy without bowel resection, but there are studies that show that it can be microscopically incomplete (10). In conclusion, in front of a patient of childbearing age with abdominal pain or bowel obstruction, endometriosis with gastro- intestinal involvement should be considered in the differential diagnosis, even without perimenstrual symptoms. It can simu - late a stenosing or fistulizing Crohn’s disease. The diagnosis and treatment will be surgical exploration with resection. Juan Antonio Asanza-Llorente1, Anastasio Serrano-Egea2, Antonio López-López1, Mónica García-Aparicio1, Teresa Calderón-Duque1 and Jesús Timón-Peralta1 1Departement of General and Digestive Surgery. 2Department of Pathology. Hospital Nuestra Señora del Prado. Talavera de la Reina, Toledo. Spain

1. De Ceglie A, Bilardi C, Blanchi S, Picasso M, Di Muzio M, Trimarchi A, et al. Acute small bowel obstruction caused by endometriosis: A case report and review of the literature. World J Gastroenterol 2008;14:3430-4. 2. Fernández Rey CL, Álvarez González SA, Díaz Solís P, Blanco González A, Costilla García S. Endometriosis ileal como causa de obstrucción de intestino delgado: diagnóstico por tomografía compu- tarizada multicorte. Rev Esp Enferm Dig 2009;12:872-4. 3. Anaf V , El Nakadi I, Simon P, Van de Stadt J, Fayt I, Simonart T, el al. Preferential infiltration of large bowel endometriosis along the nerves of the colon. Hum Reprod 2004;19:996-1002. 4. Yantiss RK, Clement PB, Young RH. Endometriosis of the intestinal tract: A study of 44 cases of a disease that may cause diverse challenges in clinical and pathologic evaluation. Am J Surg Pathol 2001;25:445-54. 5. López PA, Martín L, Vicente M, Girón O, Del Pozo M. Ileal endo - metriosis and Crohn´s disease. A difficult differential diagnosis. Cir Esp 2007;82:122-4. 6. Biscaldi E, Ferrero S, Fulcheri E, Ragni N, Remorgida V , Rollandi GA. Multislice CT enteroclysis in the diagnosis of bowel endometriosis. Eur Radiol 2007;17:211-9. 7. Cameron IC, Rogers S, Collins MC, Reed MW. Intestinal endome - triosis: Presentation, investigation and surgical management. Int J Colorectal Dis 1995;10:83-6. Fig. 1. CT scan which shows the large dilated loop of intestine longstanding stenosis (left) and contrast-filled bladder with fistula-ileum area (arrow). Fig. 2. A. Histology showing endometrial tissue in the muscular enteric layer without affecting the mucosa (HE x10). B. Immunohistochemistry which demonstrates the presence of endometrial tissue (CD10 x10). 506 LETTERS TO THE EDITOR Rev esp enfeRm Dig (m aDRiD) Rev esp enfeRm Dig 2013; 105 (8): 504-506 8. Kalu E, Richardson R, Sellu D, Kubba F. Endometriosis-associated ileo-cecal perforation in a woman on the pseudopregnancy regimen. J Minim Invasive Gynecol 2008;15:764-6. 9. Sriganeshan V , Willis IH, Zarate LA, Howard L, Robinson MJ. Col- outerine fistula secondary to endometriosis with associated chorioam- nionitis. Obstet Gynecol 2006;107(2 Pt 2):451-3. 10. Remorgida V , Ragni N, Ferrero S, Anserini P, Torelli P, Fulcheri E. How complete is full thickness disc resection of bowel endometriotic lesions? A prospective surgical and histological study. Hum Reprod 2005;20:2317-20.