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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 14  |  Issue : 2  |  Page : 76-78

Intestinal obstruction caused by rectal stricture secondary to endometriosis: A case report


1 Department of Surgery, Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Sokoto State, Nigeria
2 Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Sokoto State, Nigeria
3 Department of Pathology, Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Sokoto State, Nigeria

Date of Submission04-Oct-2022
Date of Acceptance21-Nov-2022
Date of Web Publication26-Dec-2022

Correspondence Address:
Ibrahim Umar Abubakar
Department of Surgery, Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Sokoto State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njgh.njgh_19_22

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  Abstract 

Introduction: Endometriosis is a common condition among women of the reproductive age group which manifests through variable symptoms. Intestinal involvement in endometriosis is quite common and can resemble several diseases such as Crohn’s disease, appendicitis, tubo-ovarian abscess or malignant tumour. Intestinal obstruction due to endometriosis is rare and pre-operative diagnosis is difficult because the clinical features are non-specific and can be easily confused. In a case of a patient without a history of endometriosis, diagnosis is complicated. Case Summary: The case under review is a 28-year-old female who presented initially to the gynae emergency unit with recurrent pelvic pains and subsequently developed intestinal obstruction and had surgery; pelvic adhesiolysis, Hartman’s procedure with histopathological confirmation of endometriosis. Conclusion: 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

Keywords: Endometriosis, intestinal obstruction, pelvic pain


How to cite this article:
Bashir B, Abubakar IU, Aroume AJ, Emetuma F. Intestinal obstruction caused by rectal stricture secondary to endometriosis: A case report. Niger J Gastroenterol Hepatol 2022;14:76-8

How to cite this URL:
Bashir B, Abubakar IU, Aroume AJ, Emetuma F. Intestinal obstruction caused by rectal stricture secondary to endometriosis: A case report. Niger J Gastroenterol Hepatol [serial online] 2022 [cited 2023 Feb 8];14:76-8. Available from: https://www.njghonweb.org/text.asp?2022/14/2/76/365312




  Introduction Top


Endometriosis is defined as the occurrence of endometrial glands and stroma outside the uterine cavity and myometrium.[1] 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.[2] It usually manifests in the pelvis but it has been also observed in other organs.[3] 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.[3] 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.[3],[4] 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.[3]

Endometriosis is common yet complex, as it is associated with a broad spectrum of clinical presentations.[4] 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.[5]

This report aims to highlight the need to consider intestinal endometriosis as a differential diagnosis in cases of acute abdomen.


  Case report Top


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.
Figure 1: Histopathology of Resected Strictured Rectum

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  Discussion Top


Endometriosis is a benign gynaecological disease defined as the presence of endometrial tissue outside the uterine cavity, predominantly in the pelvic compartment.[7] It is an oestrogen-dependent chronic inflammatory condition affecting women in the reproductive period, and it is associated with infertility.[7] The disease has a peak between 25 and 35 years of age.[8],[9] The percentage of patients experiencing severe symptoms or complications is about 3% of women at a fertile age.[8],[9]

The pathogenesis of endometriosis is not fully understood, but the most accepted theory suggests retrograde menstruation as the aetiology of this disease.[7] 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.[8],[9]

The most common sites of endometriosis are the ovaries, cul de sac and uterosacral ligaments[2] 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.[3] These atypical sites pose a particular challenge for accurate diagnosis.[10]

Endometriosis can present with dysmenorrhea, dyspareunia, deep pelvic pain, infertility or lower abdominal pain.[3] 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.[3],[4] Women on rare occasions suffer from acute abdominal or pelvic pain severe enough to cause them to seek emergency medical care.[4]

The involvement of the bowel in intestinal endometriosis is typically associated with the disease at other sites as presented by our patient.[4] 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.[11] Bowel obstruction due to endometriosis is rare, occurring in less than 1% of all patients,[6] and when this occurs, urgent treatment is often necessitated.[12] 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.[4] 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[4],[13] 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.[3],[5]

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.


  Conclusion Top


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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
John CT, Ikimalo JI Endometriosis. In: Kwawukume EY, Emuveyan EE, Ekele BA, Danso KA, editors. Comprehensive Gynaecology in the Tropics. 2nd ed. Acra-North: Assemblies of God Literature Center Ltd; 2017. p. 211-22.  Back to cited text no. 1
    
2.
Brown J, Farquhar C Endometriosis: An overview of cochrane reviews. Cochrane Database Syst Rev 2014;2014:CD009590.  Back to cited text no. 2
    
3.
Hwang BJ, Jafferjee N, Paniz-Mondolfi A, Baer J, Cooke K, Frager D Non-gynaecological endometriosis presenting as an acute abdomen. Emergency Radiology 2012;19:463-71.  Back to cited text no. 3
    
4.
Molina GA, Ramos DR, Yu A, Paute PA, Llerena PS, Alexandra Valencia S, et al. Endometriosis mimicking a cecum mass with complete bowel obstruction: An infrequent cause of acute abdomen. Case Rep Surg 2019;2019:7024172.  Back to cited text no. 4
    
5.
Khwaja SA, Zakaria R, Carneiro HA, Khwaja HA Endometriosis: A rare cause of small bowel obstruction. British Medical Journal Case Reports2012;13:13-6.  Back to cited text no. 5
    
6.
Parasar P, Ozcan P, Terry KL Endometriosis: Epidemiology, diagnosis and management. Current Obstetrics and Gynaecology Reports 2017;6:34-41.  Back to cited text no. 6
    
7.
Alexandrino G, Lourenço LC, Carvalho R, Sobrinho C, Horta DV, Reis J Endometriosis: A rare cause of large bowel obstruction. GE Port J Gastroenterol 2018;25:86-90.  Back to cited text no. 7
    
8.
Parazzini F, Esposito G, Tozzi L, Noli S, Bianchi S Epidemiology of endometriosis and its comorbidities. Eur J Obstet Gynecol Reprod Biol 2017;209:3-7.  Back to cited text no. 8
    
9.
Vercellini P, Viganò P, Somigliana E, Fedele L Endometriosis: Pathogenesis and treatment. Nat Rev Endocrinol 2014;10:261-75.  Back to cited text no. 9
    
10.
Baden DN, van de Ven A, Verbeek PC Endometriosis with an acute colon obstruction: A case report. J Med Case Rep 2015;9:150.  Back to cited text no. 10
    
11.
Lopez CA, Hernandez GA, Hidalgo GPA, Rodriguez GR, Martin MJL, Zapardial I, et al. Ileocecal endometriosis: Diagnosis and management. Taiwan Journal of Obstetrics and Gynecology 2017;56:243-46.  Back to cited text no. 11
    
12.
Vahdat M, Sariri E, Mehdizadeh A, Najmi Z, Shayanfar N Colonic obstruction as an unusual presentation of endometrioma. Surgical Laparoscopy, Endoscopy and Percutaneous Techniques 2013;23:131-3.  Back to cited text no. 12
    
13.
Ozel B, Pickhardt PJ, Kim DH, Schumacher C, Bhargava N, Winter TC Accuracy of routine non-targeted CT without colonography technique for the detection of large colorectal polyps and cancer. Disease of the Colon and Rectum 2010;53:911-8.  Back to cited text no. 13
    


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