The Asymptomatic Endometrial Cecal Polyp: A Uncommon Occurrence Discovered in an Even More Uncommon Way

Purpose: Involvement of the gastrointestinal tract is reported to affect between 3% and 37% of patients with pelvic endometriosis. When endometriosis does involve the GI tract, it commonly involves the recto-sigmoid (72%), the rectovaginal septum (13%), small intestine (7%), cecum (3.6%) and the appendix (3%). Endometriosis of the appendix with or without acute inflammation is also a very rare condition and has been sparsely published in the literature. We are reporting a case report of a female patient found to have a large polypoid lesion at the appendiceal orifice that was treated with laparoscopic excision. On pathology, the resected lesion was found to be consistent with endometriosis. Our patient is a 50-year old female with no significant past medical history who had been referred by her primary care physician for a screening colonoscopy. The patient prior to her colonoscopy denied any abdominal pain, pain with defection or urination, and admitted to a fulfilling marital life without symptoms of dyspareunia. During colonoscopy a large 2 cm sessile polypoid lesion located at the superior aspect of the appendiceal orifice was noted. Numerous biopsies were obtained of the lesion, had hard consistency when probed with biopsy forceps. Pathology revealed colonic mucosa with lymphoid aggregates. Given the nature of the lesion the patient was referred for a laparoscopic partial cecal resection with appendectomy and left salpingo-oophorectomy. During the surgery, multiple endometrial pockets were noted and the appendix was engulfed by endometriosis. The pathology findings of this surgery found endometriosis involving colon and appendix with cystic degeneration of the ovary on the same side. The occurrence of this disease process is 0.054% in a recent study of 50,000 collections of human appendiceal specimens. Patients with this disease typically have abdominal pain and other manifestations of endometriosis while our patient was completely asymptomatic. On pathologic evaluation if H&E stain fails, appendiceal endometriosis can be suspected by an increased density of mast cells in the muscularis propria. We recommend up-front mucosal biopsy for lesions with a normal appearing mucosa but firm fixed mucosal consistency. The role of EUS has also not been readily applied to this disease process and we plan to consider its utility in diagnosing endometrial implants of the colon in future patients.