Incidental discovery of a rectal polypoid lesion.

© Copyright 2018. Korean Association for the Study of Intestinal Diseases. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. casionally be challenging due to the various clinical manifes- tations. Endometriosis involves the colon and rectum in about 5% of cases. Colorectal endometriosis lesions can be deeply infiltrating. Most colorectal lesions do not infiltrate the full thickness of the colorectal wall. In a systematic review of pa - tients who underwent large bowel resection for colorectal en- dometriosis, 38% of lesions penetrated to the submucosa and only 6% invaded the mucosa. 1 Sigmoidoscopy or colonoscopy is rarely useful to diagnose bowel endometriosis as lesions that penetrate the mucosa are unusual. It is, however, important to perform colonoscopy pri- or to surgery in order to exclude a malignancy if there are symptoms suggestive of a bowel neoplasm and to assess pos- sible colorectal stricture in women with symptoms suggestive of partial bowel obstruction. 2,3 In a study of 83 women under- going surgical resection for bowel endometriosis, 8% (7/83) had a concurrent malignancy. 3 It can sometimes be difficult to differentiate between colorectal endometriosis and colon cancer or other condi - tions. Polypoid colorectal endometriosis is particularly diffi - pISSN 1598-9100 • eISSN 2288-1956 https://doi.org/10.5217/ir.2018.00129 Intest Res 2018;16(4):648-649 Incidental discovery of a rectal polypoid lesion Hyun Seok Lee Department of Internal Medicine, K yungpook National University Hospital, School of Medicine, K yungpook National University, Daegu, Korea Received September 17, 2018. Revised September 21, 2018. Accepted September 22, 2018. Correspondence to Hyun Seok Lee, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, 807 Hoguk-ro, Buk-gu, Daegu 41404, Korea. Tel: +82-53-200-2603, Fax: +82-53-200-2027, E-mail: [email protected] IMAGES OF THE ISSUE Question: A 40-year-old woman underwent screening colo- noscopy at another hospital. She had no abdominal symp - toms. Colonoscopy showed multiple polypoid lesions at the proximal rectum. Pathologic results of forceps biopsy showed a hyperplastic polyp with surface ulceration. She was trans - ferred to the outpatient clinic at K yungpook National Univer- sity Hospital for further evaluation and management. Because malignancy could not be ruled out, it was decided that she un- dergo polypectomy on the polypoid lesion (Fig. A) for patho- logic diagnosis. During colonoscopy, submucosal saline was injected before snaring, and the lesion showed a positive non- lifting sign. However, endoscopic mucosal resection (EMR) was performed (Fig. B) to identify pathologic features despite incomplete resection (Fig. C). What is the most likely diagnosis? Answer: Colorectal Endometriosis The pathologic diagnosis of the EMR specimen was colorectal endometriosis (Fig. D, H&E, ×40). Endometriosis is defined as the presence of endometrial glands and stroma at extrauterine sites including the pelvis. The preoperative diagnosis can oc- A B C D https://doi.org/10.5217/ir.2018.00129 • Intest Res 2018;16(4):648-649 649 www.irjournal.org cult to distinguish from a colorectal tumor. Endometriosis is definitively diagnosed with histologic evaluation of a biopsied lesion. 4 If mucosal abnormalities are identified during colo - noscopy, targeted biopsies should be obtained. However, if the colorectal mucosa is not involved, an accurate diagnosis cannot be made with a colonoscopic biopsy. Therefore, nor - mal biopsy results may not rule out colorectal endometriosis and further evaluation may be needed. In this case, pelvic MRI did not provide additional informa- tion on the patient’ s colorectal endometriosis. Although ab - dominal CT or MRI is an important tool in preoperative evalu- ation of colorectal endometriosis, a surgical procedure can help make a tissue-based diagnosis if a colonoscopy fails to of- fer a pathologic diagnosis. Diagnostic laparoscopy or laparot- omy can help to diagnose and confirm endometriosis patho- logically. 3 FINANCIAL SUPPORT The author received no financial support for the research, au- thorship, and/or publication of this article. CONFLICT OF INTEREST No potential conflict of interest relevant to this article was re- ported. AUTHOR CONTRIBUTION Hyun Seok Lee selected the case, wrote the manuscript, pro - cessed the images and pathologic findings, and reviewed the final version of the manuscript. REFERENCES 1. Meuleman C, Tomassetti C, D’Hoore A, et al. Surgical treatment of deeply infiltrating endometriosis with colorectal involvement. Hum Reprod Update 2011;17:311-326. 2. Remorgida V , Ferrero S, Fulcheri E, Ragni N, Martin DC. Bowel endometriosis: presentation, diagnosis, and treatment. Obstet Gynecol Surv 2007;62:461-470. 3. Kaufman LC, Smyrk TC, Levy MJ, Enders FT, Oxentenko AS. Symptomatic intestinal endometriosis requiring surgical resec - tion: clinical presentation and preoperative diagnosis. Am J Gas- troenterol 2011;106:1325-1332. 4. Kanthimathinathan V , Elakkary E, Bleibel W, Kuwajerwala N, Conjeevaram S, Tootla F . Endometrioma of the large bowel. Dig Dis Sci 2007;52:767-769.