Endometriosis is defined as the occurrence of endometrial glands and stroma outside the uterine cavity and myometrium. The prevalence of endometriosis is about 10–15% of the general population, however complications in diagnosis such as the need for visualization to confirm its occurrence suggest that the real prevalence could be higher. It usually manifests in the pelvis but it has been also observed in other organs. One of such non-gynaecological cases known as intestinal endometriosis manifest in 3–37% of endometriosis patients and commonly involves the rectum and sigmoid colon. Endometriosis of the gastrointestinal tract is usually asymptomatic but symptoms such as abdominal pain, distention, vomiting, diarrhoea, constipation, dyspareunia, and hematochezia could occur in some cases. These symptoms can mimic other pathologies such as Crohn’s disease, appendicitis, tubo-ovarian abscesses, intestinal obstructions or malignancies, especially in patients without a previous history of endometriosis.
Endometriosis is common yet complex, as it is associated with a broad spectrum of clinical presentations. Despite chronic pelvic pain being common, women having endometriosis in unusual sites or experiencing complications may present with acute abdominal pain in up to 8% of the cases and require urgent medical attention.
This report aims to highlight the need to consider intestinal endometriosis as a differential diagnosis in cases of acute abdomen.
A 28year old spinster presented with recurrent colicky lower abdominal/pelvic pain of 4months duration and acutely developed abdominal distension, vomiting and constipation. Examination revealed an acutely ill looking young lady, not pale, anicteric, well-hydrated, and afebrile. Her abdomen was distended and moved with respiration, no organomegaly, no ascites, bowel sounds hypoactive, and a digital rectal examination revealed scanty faeces in the rectum, no masses. Other systemic examinations were unremarkable.
A plain abdominal x-ray revealed dilated bowel loops with haustration. Results of other investigations were unremarkable. She had laparotomy which revealed dilated small bowel, left-sided colon with the collapsed proximal rectum and dense pelvic adhesions. She had adhesiolysis with Hartmann’s procedure. Histopathological examination of the resected specimen revealed rectal endometriosis as shown in Figure 1. She had reversal of Hartman’s Procedure and follow up visit.
Endometriosis is a benign gynaecological disease defined as the presence of endometrial tissue outside the uterine cavity, predominantly in the pelvic compartment. It is an oestrogen-dependent chronic inflammatory condition affecting women in the reproductive period, and it is associated with infertility. The disease has a peak between 25 and 35 years of age. The percentage of patients experiencing severe symptoms or complications is about 3% of women at a fertile age.
The pathogenesis of endometriosis is not fully understood, but the most accepted theory suggests retrograde menstruation as the aetiology of this disease. Menstrual blood transport cells from the lining of the uterus which comes to lie on the surfaces of the pelvis where they attach, grow, and develop into endometriosis. Endometriosis implants on the peritoneum and pelvic viscera adhere to the intestinal serosal and may invade the submucosa.
The most common sites of endometriosis are the ovaries, cul de sac and uterosacral ligaments while atypical non-gynaecological sites for the disease include the gastrointestinal, appendiceal, urinary tract and abdominal wall tissues, with additional reports on the pulmonary tract, lymphatic system, skin, musculoskeletal system, and central nervous system. These atypical sites pose a particular challenge for accurate diagnosis.
Endometriosis can present with dysmenorrhea, dyspareunia, deep pelvic pain, infertility or lower abdominal pain. These symptoms occur more commonly in women of reproductive age and may depend on the location and depth of the disease; however, the extent of the disease may not necessarily be correlated with the severity of the symptoms. Women on rare occasions suffer from acute abdominal or pelvic pain severe enough to cause them to seek emergency medical care.
The involvement of the bowel in intestinal endometriosis is typically associated with the disease at other sites as presented by our patient. Bowel is the most affected extragenital location (3–12%), mostly the rectosigmoid junction (50–90%). There may also be involvement of the small bowel (2–16%), appendix(3–18%), and caecum (2–5%). The ileum is affected in 4.1% of patients. Bowel obstruction due to endometriosis is rare, occurring in less than 1% of all patients, and when this occurs, urgent treatment is often necessitated. However, in the case of patients without a prior history of endometriosis, the differential diagnostic procedures can cover a broad spectrum, and making the correct clinical and radiologic diagnosis in an emergency setting can be challenging. Due to the unspecific symptoms of endometriosis and the probability of misidentification of the observed masses on the CT scans, the diagnosis is only made after surgical and histopathological analysis as it occurred with our patient. Prompt and accurate clinical and radiological evaluation is necessary because complications of endometriosis, such as bowel obstruction or perforation, may require immediate surgical intervention.
In the case above, it was not possible to establish an accurate preoperative diagnosis based on the symptoms and signs and images seen. However, due to intestinal obstruction, she had surgery with histological confirmation of endometriosis.
Despite being rare, intestinal endometriosis can lead to a series of presentations of acute abdomen requiring intervention as highlighted above, hence the need for vigilance and heightened suspicion.
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Conflicts of interest
There are no conflicts of interest.
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