A Rare Cause of Colonic Obstruction

Patients are seen often in the clinical setting for constipation and abdominal pain. In this case presentation, we will describe a patient with those symptoms who had developed a high-grade sigmoid colon stricture due to extensive endometriosis implants. It is classically defined as the presence of endometrial glands and stroma at one or more extrauterine sites. Although it is estimated to affect over seven million women in the United States, endometriosis in the gastrointestinal (GI) tract is less common. Only about 17.4 percent of endometriosis that affects the GI tract is found in the sigmoid colon; even more rare, is it leading to colonic obstruction. A 42 year-old female with a past medical history of chronic constipation and endometriosis presented with abdominal pain and recurrent episodes of non-bilious, non-bloody vomiting for two hours. The abdominal pain was described as sharp, colicky, 8/10 in intensity, intermittent, localized to her left lower abdomen and associated with worsening constipation. Review of systems was notable for a decrease in the frequency and size of her bowel movements. She had been taking polyethylene glycol daily for her constipation and a surgical history of a total vaginal hysterectomy. She was hemodynamically stable and her physical examination was notable for mild left lower quadrant tenderness to palpation without rebound tenderness, guarding or rigidity. Laboratory data was unremarkable. A CT scan identified a large amount of stool in her colon and wall thickening in the sigmoid colon. A colonoscopy was performed which revealed a high-grade stricture 15 cm from the anal verge. CT-colonography confirmed a 3 cm segment suspicious for malignancy. She subsequently underwent a sigmoid resection of the stricture and a primary anastomosis. Pathology found extensive endometriosis with marked reactive fibrosis and severe bowel stricture. There are only 11 known published case reports related to sigmoid colon stricture due to endometriosis, with the first reported in 1962. Endometriosis is a condition that can affect the GI tract and manifest itself in unusual presentations. It should be considered in the differential diagnosis of bowel obstruction and stricture even in patients who are post menopause and have had a previous hysterectomy. Confirmatory diagnosis will unlikely be made by intestinal mucosal biopsy and is usually obtained via surgical resection.Figure 1