Bowel endometriosis: case report

1. Darzi A. Minimal Access Surgery. In: Kirk RM, Mansfield AO, Cochrane JP Seds. Clinical Surgery in General. Churchill Livingstone, 1999; 240-244. 2. Cushieri A, Houston G. Minimal access therapy. In: Cushieri A, Steele RJC, Moossa A Reds. Essential Surgical Practice. London: Arnold, 2001; 493-520. 3. Palanivelu C. CIGES Atlas of Laparoscopic Surgery. Jaypee Brothers 2003; 3-32. Bowel endometriosis: case report 1 2 3 Ajith Lamahewage , JPM Kumarasinghe , NG Ranawaka1 2 3 Senior Lecturer, Department of Pathology, Senior Lecturer, Department of Surgery, Lecturer, Department of Pathology, Faculty of Medicine, University of Ruhuna, Galle.

Endometriosis is defined as the presence of endometrial glands and/or stroma in extra uterine sites. It is principally a disease of women in active reproductive life. This disorder often causes infertility, dysmenorrhoea, pelvic pain, and symptoms related to the affected organs. It occurs in the following sites in descending order of frequency: ovaries, uterine ligam ents, rectovaginal septum , pelvic peritoneum , laparotomy scars and rarely in umbilicus, vagina, bladder and bowel. Three potential explanations of the origin of endom etriosis are; the regurgitation-im plantation theory, the metaplastic theory and the vascular or lymphatic dissemination theory. In addition hormonal and immune genetic factors may play a role for the susceptibility to develop endometriosis [1]. Case Report A 37 year-old female was referred to the surgical casualty ward with a vague pain in the right side of the abdomen. The clinical diagnosis was an acute appendicitis. Conventional appendectomy was attempted but a mass lesion involving the wall of the ileo-caecal junction was found. T herefore, an exploratory laparatom y w as carried out. Part of the ascending colon, caecum along with the appendix and a part of ileum was removed and end to end anastamosis was made. Pathological specimen consisted of a segment of the ascending colon, caecum along with the appendix and a segment of ileum. A white, constricting lesion was seen involving the wall of the bowel at the ileocael junction which appeared to involve the serosa, too. The lesion measured 4×2×2 cm. Appendix looked macroscopically normal. Eleven enlarged mesenteric lymph nodes were recovered. Histological sections from the constricting lesion in the ileo-cecal junction showed several foci of endometrial glandular structures accompanied by endometrial stroma embedded in muscularis propria (Figure 1). They were lined by a single layer of columnar epithelium with basally located nuclei. No atypical features were noted. Galle Medical Journal, Vol. 12: No.1, September 200760 Case Reports Occasional mitoses were seen in the stroma. Intestinal mucosa of the ileum and caecum showed a moderate chronic inflammatory cell infiltration. Ascending colon and appendix were microscopically normal. All the eleven lymph nodes showed features of reactive hyperplasia. Figure 1 - Histological section of the lesion in the ileo - caecal junction

Bowel endometriosis is very rare. It is usually an incidental finding in the gut, but some examples present themselves as an obstructing tumefactive m ass that closely sim ulates an intestinal neoplasm [2]. Although some women with bowel endom etriosis m ay be asym ptom atic, the m ajority of them develop a variety of gastrointestinal complaints. Except for rectal nodules bow el endom etriosis cannot be diagnosed by physical examination. Therefore, imaging techniques such as double contrast barium enema, transvaginal ultrasonography; rectal endoscopic ultrasonography, magnetic resonance imaging (M RI) and mu lti slice computed tomography enterolysis should be used [3]. Medical management of bowel endometriosis is currently speculative. S everal studies demonstrated an improvement in quality of life after surgical excision of the lesion. Bowel endometriotic nodules can be removed by various techniques; m ucosal skinning, nodulectomy, full thickness disc-resection and segmental resection of the bowel [2].

1. H C A n d erso n , E n d o m etrio sis. In : W .S t. rd Symmer's. Systemic Pathology, 3 Edition, Vol. 6, Churchill Livingstone, 1990; 241-62. 2. Patrick L, Fitzgibbons. Pseudoneoplastic lesion of alimentary treat. In: Mark R W ick, Peter A H u m p h rey, Jo n H R itter. P ath o lo g y o f st Pseudoneoplastic Lesions, 1 Edition, Lippincott, Raven: 1997: 149-150. 3. Juan Rosai. Female genital trent. In: Juan Rosai. th Ackerman's Surgical Pathology, 9 Edition, Vol 2: Mosby , 2004; 1569-635. Low rectal carcinoma with liver metastasis 1 2 3 HCM Hettiarachchi, KB Galketiya, SS Edirimuni1 2 3 Registrar in Surgery, Consultant Surgeon,Senior Registrar in Surgery, Teaching Hospital, Karapitiya, Galle.

35-45% of patients with colorectal carcinoma develop hepatic metastases and if left untreated, survival beyond five years is extremely rare. In appropriately selected patients liver resection is associated with a 30-40% 5-year survival and a 20 % longterm disease free survival. Case history A sixty year-old female, presented with bleeding per rectum and alteration of bowel habits of nine Case Reports Galle Medical Journal, Vol. 12: No.1, September 2007 61