ENDOMETRIOSIS AS A CAUSE OF INTESTINAL OBSTRUCTION

Since Sampson (I92I) described a case of endometrioma of the sigmoid colon, increased interest has been taken by surgeons in extragenital endometriosis. The site where this condition is most liable to give rise to complications is in the intestine where small and large bowel obstruction may result from the cyclic haemorrhages around and in the endometrial glands and stroma. The end-result of this process is a profuse fibroblastic reaction and cicatrization probably due to tissue response to free haemosiderin analagous to the cirrhotic liver that may occur in haemosiderosis. This leads to constriction of the bowel lumen, often in napkin-ring fashion. Obstruction may also occur due to encroachment on the bowel lumen of a mass of submucous endometrial gland tissue, designated 'an endometrioma,' without actual constriction of the bowel. This latter condition has a prediliction for the sigmoid colon. Occasionally, acute kinking and volvulus of the small bowel may occur due to dense adhesions caused by endometriosis (Grigsby, I94I). When the small bowel is involved, in almost all cases the obstructive process is in the terminal ileum. Only in one of the reported cases was the obstructive process 60 cm. above the ileo-caecal valve, and the case presented as a fish-bone perforation of the small bowel above the site of endometrial involvement of the ileum (Gale, 93 I). Many of the patients with ileal involvement have been diagnosed pre-operatively as having acute appendicitis (Colcock, I950; Clark I95I, et al.,) One case was diagnosed as torsion of the pedicle of an ovarian cyst, and at laparotomy the ileal lesion was found to have caused an ileo-ileal intussusception (Cunningham and Viner Smith, 1948). The rectum is the commonest site of large bowel invasion. This is usually due to direct spread of the endometrial process from the pouch of Douglas, or from a ' chocolate cyst' of the ovary into the rectal wall. Obstruction due to rectal involvement is rare, however, though in two of the three cases recorded by Graves (I927) the lumen of the rectum was obstructed. This is due to the anatomical fact that the diameter of the rectal ampulla is relatively large, and this is obvious to the surgeon when an anterior resection of the rectum for carcinoma is being performed. On the other hand, when the sigmoid colon is involved by the endometrial process, obstruction is much more liable to occur, and endometriosis at this site must be considered in the differential diagnosis of carcinoma of the sigmoid in women. The purpose of this paper is to describe two further cases of endometriosis of the intestine which caused obstruction, the first in the ileum and the second in the sigmoid colon, and to discuss some points chiefly gleaned from the literature that may help in diagnosing and treating these patients.