Endometriosis-Induced Bowel Ischemia

Introduction: A 49 year old female presented with one day of abdominal pain, nausea, vomiting, and diarrhea. On initial exam, she was found to be hypotensive and tachycardic, with acute renal failure. Imaging demonstrated a segmental colitis involving the descending and sigmoid colon. The patient was determined to have an acute abdomen, with a nondiagnostic exploratory laparoscopy. The patient's subsequent six week hospital course was marked by general symptomatic improvement on variable antibiotic and steroid trials, with a differential diagnosis including infectious colitis, ischemic colitis, and IBD. However, the patient experienced protracted renal failure requiring dialysis and hemodynamic instability. Initial flexible sigmoidoscopy to the rectosigmoid on day nine of admission revealed friable mucosa and pseudomembranes, with patchy chronic inflammation on pathology. Of note, c difficile testing was negative, with vascular studies demonstrating no fixed defects, and non-significant ANCA, ANA, and complement results. A repeat CT showed distal colonic stricturing and distension. A second endoscopic procedure on week 2 showed marked edema and friability, with narrowing of the lumen at the rectosigmoid. Pathology was nonspecific given the degree of superficial tissue necrosis. A third endoscopy one week later revealed a non-healing stricture despite the aforementioned therapies. The patient returned to the OR and received a rectosigmoidectomy. Surgical pathology confirmed transmural endometriosis with fibrosis. Colonic mucosa showed active inflammation with reactive changes including mild crypt distortion, consistent with a resolving colitis; in this case most likely due to obstruction of an ischemic origin. Discussion: Endometriosis can involve the GI tract in 3-34% of cases. The rectosigmoid colon is most frequently affected. Endometriosis of the bowel generally involves the serosa and muscularis propria, avoiding the mucosa and submucosa, making it difficult to detect with routine endoscopy. Bowel based endometriosis can present with a wide array of symptoms, in particular pain and bleeding. The nodules themselves can become surrounded by smooth muscle hyperplasia and fibrosis, resulting in stenotic strictures that can cause obstruction. However, in this case, the disease also microscopically presented with a vascular, ischemic like phenomena contributing to the evolving stricture. Key words: colon, endometriosis, ischemia.