Abstracts: CLINICAL VIGNETTES
Purpose: A 28-year-old previously healthy female complained of constipation for several months and intermittent hematochezia for one week, noting bright red blood coating her stools. She also noted lower abdominal pain relieved with a bowel movement. She had no fever, chills, weight loss or relationship of symptoms to menstrual periods. Physical exam including a pelvic examination by a gynecologist was normal. The stool was hemoccult positive. Her CBC was normal. A CT Scan of the abdomen and pelvis was normal. Colonoscopy showed a firm, multi lobulated 4 × 5 cm broad-based mass 10 cm from the dentate line that occupied approximately 1/3 of the circumference of the lumen. Biopsies of the mass showed colonic mucosa with changes of mucosal prolapse with foci beneath the muscularis mucosa containing spindle-shaped cells and in one section a small endometrial-type gland indicative of endometriosis. Immunoperoxidase staining showed CD10 positive and C-KIT negative cells consistent with endometriosis. The patient has been referred to a gynecologist specializing in management of endometriosis and is scheduled for laser ablation and/or excision.
Conclusion: It is estimated that 4–17% of all menstruating women have endometriosis, with 3–34% of these cases involving the gastrointestinal tract. The rectum and rectosigmoid junction account for 70–93% of all intestinal endometriosis. Colonic mucosal implants are unusual and the disease is rarely diagnosed by endoscopic biopsy. Although most gastrointestinal endometriosis is asymptomatic, symptoms may include abdominal pain, dyschezia, tenesmus, vomiting, diarrhea, constipation, melena or hematochezia. Symptoms do not always correlate with the menstrual cycle. Endometriosis is thought to result from retrograde menstruation leading to implantation on the peritoneum, pelvic viscera, small bowel or colon with occasional invasion through the submucosa. Gastrointestinal endometriosis may be difficult to diagnose, especially if there is absence of mucosal involvement. The differential diagnosis includes infection, ischemia, malignancy and IBD. Treatment may involve hormonal manipulation or segmental resection, particularly with obstructing lesions. We present a case of gastrointestinal endometriosis presenting with constipation and hematochezia in a 28-year-old female diagnosed by colonoscopy and mucosal biopsy. Gastroenterologists should be aware of mucosal endometrial implants as a potential cause of rectal bleeding in young women.