Intestinal endometriosis Clinical History

The woman was hospitalized four times because of abdominal pain in the right lower quadrant (RLQ), constipation, vomiting, anorexia and weight loss, with 8 months of evolution. On physical examination she presented an abdominal distension with a palpable and painful mass in the RLQ and signs of peritoneal irritation. Imaging Findings Abdominal ultrasound (Fig. 1) demonstrated a conglomerate of distended intestinal loops in the RLQ surrounded by fluid. Several bowel loops exhibited mural thickening. After some days, abdominal and pelvic CT did not show intestinal alterations and the woman felt better after medical therapy. Suprapubic US (Fig. 2) revealed in the left ovary a cystic lesion measuring 4.7 cm in the major axis. A small effusion was visible in the cul-de sac. Colonoscopy with ileoscopy was normal, without endoluminal or mucosal lesions. CT enteroclysis (Fig. 3) showed a mass in the terminal ileum, involving the ileocecal valve and conditioning dilatation of proximal loops. An exploratory laparotomy with ileocecal resection was performed and histopathologic and immunohistochemical analyses yielded endometriosis of the ileocecal valve, cecum and appendix conditioning stenosis of the terminal ileum. Discussion Endometriosis is defined as the presence of functional endometrial glands and stroma outside the uterine cavity. There are three theories to explain this pathology – metastatic (retrograde menstruation), metaplastic, and induction theories, the first being the most accepted. According to this theory, endometrial cells leave the uterine cavity via retrograde menstruation and implant on serosal surfaces outside the uterus. However, presently, one is discussing a multifactorial aetiology. Endometriosis affects women during their reproductive years but there are cases of endometriosis in the peri-/post–menopause. Ovaries are the most common site for endometriosis implants (76%), followed by the cul–de-sac (69%). Intestinal endometriosis is less common (3-37%) and generally affects the rectosigmoid colon (4%).