Gastrointestinal: A case of mid‐ileum endometriosis presenting as small bowel intussusception treated by single‐balloon enteroscopy with endoscopic full‐thickness resection

A 47-year-old lady with a history of ulcerative colitis on infliximab maintenance therapy presented with intermittent severe abdominal pain for a few days. Physical examination revealed no palpable abdominal mass. Computed tomography of abdomen and pelvis revealed a short-segment ileoileal intussusception in the right lower abdomen with no evidence of proximal bowel obstruction. A follow-up computed tomography enterography delineated a 9-mm intraluminal mass with macroscopic fat attenuation at the mid-ileum, possibly a submucosal lipoma, which acted as the lead point for the intussusception (Fig. 1a). As she remained stable with no evidence of intestinal obstruction or ischemia, her intussusception was managed non-operatively. She subsequently underwent single-balloon enteroscopy, which confirmed the presence of a 25-mm polypoid lesion at the mid-ileum, which was soft and indentable when pressure was applied using forceps (Fig. 1b). The location of the lesion was marked by endoscopic tattooing, to facilitate localization in case of need for subsequent surgery. The base of the polyp was then captured using endoloop (Fig. 1c), and hot snare resection was performed. The resection base was further secured by additional application of endoscopic clips (Fig. 1d). Although the resected specimen had the macroscopic appearance of a lipomatous lesion, the eventual histology was that of endometriosis with no malignant features, resected in full thickness (Fig. 2). Endometriosis is an inflammatory disease characterized by the presence of ectopic endometrial tissue at extrauterine sites. It is commonly confined to the pelvis but may rarely involve distant organs such as the intestines. There had been studies showing associations of inflammatory bowel disease with endometriosis and their coexistence, but there were mainly case–control studies, clinical series, and case reports. Clear analysis on a cause–effect association between these two pathologies is still lacking, and temporality of diagnosis is still unclear. Intussusception is a surgical emergency. Although it is more common in the pediatric population, it is a much rarer cause of bowel obstruction in adults with an incidence of < 1%. In a patient with inflammatory bowel disease who presents with intussusception, the top concerns would be the presence of underlying malignancy as a lead point, viral infections, or surgical adhesions. Although our patient was fortunate to have benign histology, it is important to highlight that the lead point of small bowel intussusception may be malignant origin in up to 30% of cases. Even if it is not malignant, intussusception can cause severe complications such bowel ischemia, bowel perforation, sepsis, shock, and peritonitis. This case also highlights the feasibility of single-balloon enteroscopy and endoscopic resection as a minimally invasive curative treatment option to prevent disease recurrence.