Endometriosis of the Ileocecal Valve in a Young Asymptomatic Female

Purpose: The gastrointestinal tract is the most common site of extra-pelvic endometriosis. Most commonly the rectum, sigmoid colon, terminal ileum and appendix are involved. Patients can present with abdominal pain, rectal bleeding, bowel obstruction or perforation. We present a young asymptomatic patient with endometriosis of the Ileocecal valve. Methods: 22 yr old African American female was found to have bilateral complex ovarian cysts on evaluation for an episode of left flank pain. CT Abdomen and Pelvis showed a soft tissue density in the cecum. Patient was lost to follow up and presented 3 years later with right lower quadrant abdominal pain and diarrhea for 1 day. On physical examination there was right lower quadrant abdominal tenderness and thick, foul smelling, vaginal discharge. Laboratory studies showed a normal CBC and Urinalysis with 24 RBC,47 WBC, small leukocyte esterase. Repeat CT Abdomen and Pelvis showed no interval change in the cecal mass, no evidence of appendicitis and reduction in size of the ovarian cysts. Patient was treated for PID with resolution of her abdominal pain. Colonoscopy showed a large, irregular, polypoidal mass in the cecum which seemed to originate from the ileocecal valve. Biopsy showed colonic mucosa with non-specific chronic inflammation. Patient was asymptomatic and delayed her surgery for five months. Results: Because of diagnostic uncertainty and the large mass patient underwent right hemicolectomy. Intraoperatively a firm rubbery mass involving the terminal ileum and cecum was found with enlarged mesenteric lymph nodes. There were dense pelvic adhesions. On pathological examination there was 6.5 cm endometrioma of the ileocecal valve and endometriosis of terminal ileum. The mesenteric lymph nodes were reactive. Conclusion: Our case illustrates the diagnostic challenge of intestinal endometriosis. Our patient had cecal involvement which is uncommon. She also did not have recurrent abdominal symptoms that could be ascribed to the ileocecal endometriosis. Endoscopic biopsies as in our case, usually yield insufficient tissue for a definitive pathologic diagnosis as endometriosis involves the deeper layers of the bowel wall. Laparotomy/Laparoscopy is often required for making a diagnosis and for treatment.Figure: Endometriosis of ileocecal valve