A Rare Cause of Small Bowel Obstruction

Purpose: Objective: To present a case of endometriosis as a rare cause of small bowel obstruction. Case presentation: A 34-year-old Caucasian female presented with a 6-week history of intermittent and sharp periumbilical abdominal pain associated with nausea and vomiting. The symptoms were not related to her menstrual cycles. She denied any fever and weight loss and no history of melena, hematemesis or hematochezia. On examination, abdomen was mildly distended and diffusely tender to palpation with no rebound tenderness or guarding. Rectal examination was unremarkable. Lab data was significant only for hemoglobin of 11.9 g/dL. Abdominal series showed dilation of some of the small bowel loops in the mid-abdomen. Computed tomography of the abdomen and pelvis revealed dilation of the majority of the small bowel with thickening of multiple small bowel loops distally with a point of transition noted in the distal terminal ileum just a few centimeters above the ileocecal valve. Colonoscopy was incomplete secondary to poor bowel preparation. Hospital course: On laparoscopy, there were several burgundy-colored peritoneal implants that were held to the small bowel by small fibrous adhesions. The patient underwent laparoscopic hand assisted partial resection of the terminal ileum and cecum with side to side antiperistaltic anastomosis. On further evaluation of the resected specimen there was a circumferential submucosal terminal ileal mass (3.5*3.5*2.0 cm) 2.3 cm from the ileocecal valve and 4 cm from the proximal margin that constricted the small bowel lumen to approximately 8mm in diameter. The histology of the specimen showed extensive endometriosis involving the mucosa, muscularis mucosae and serosa of the small bowel (Figure 1).[712] Figure 1: Endometriosis involving mucosa, muscularis mucosae and serosa of the small bowel.Discussion: In 12 to 37 % of patients with endometriosis, the gastrointestinal tract is involved. Gastrointestinal endometriosis is often a diagnostic challenge. The presentation ranges from relapsing bouts of abdominal pain, abdominal distention, tenesmus, constipation, diarrhea, rectal bleeding, and painful defecation. The symptoms may or may not be related to menses. The diagnosis is made from the pathological exam of the surgically resected specimen.