A 43-year-old female noticed hematochezia and lower-right abdominal pain during menstruation. Her family doctor detected a mass by computed tomography at the ileocecum. She was referred to our hospital and colonoscopy was per- formed. We observed extrinsic pressure resulting in mucosal change at the ileocecum. We also observed a submucosal tumor-like lesion at the rectosigmoid. We performed biopsy from both lesions, both were benign. Ileocecal resection and rec- tal low anterior resection were performed for diagnosis. Redness, induration and serosal dimpling were recognized at the ileocecum, rectosigmoid and upper rectum. All lesions had endometorial tissue in muscular layer, so pathological diagnosis was bowel endometriosis. Bowel endometriosis occurring in multiple parts and where two colectomies were performed sim- ultaneously is very rare. To determine the optimal method of treatment for the bowel endometriosis, detailed preoperative examination must be performed, speciﬁcally complete surgical resection of the lesion for deﬁnite diagnosis. hematochezia and right-lower abdominal pain during menstru- INTRODUCTION ation, the symptoms continued over 3 years. At 43 years old, Endometriosis is a disease where endometrial tissue presents although she no longer noticed the same symptoms, she had outside of the endometrium or myometrium . It occurs in right-side chest and back pain during menstruation so visited ~6–10% of the females of reproductive age . the doctor. A tumor of the ileocecum and right pneumothorax We experienced a case of bowel endometriosis treated with were discovered by computed tomography (CT). Pneumothorax simultaneous ileocecal and rectal resection. There were three was improved by conservative treatment. Submucosal tumor reasons to perform simultaneous resection: lesions occurred in (SMT) was discovered at the rectosigmoid (RS) by colonoscopy the two different parts, deﬁnite diagnosis was not made, or (CS). The patient was referred to our hospital. A 3 cm size mass bowel stenosis was detected. Bowel endometriosis occurring in was discovered in the right-lower abdomen. Rectal examin- the multiple parts and where two colectomies were performed ation was unremarkable and laboratory data was normal. CS simultaneously is very rare. showed the SMT with erosion at RS (Fig. 1a). As the scope could not pass through the sigmoid colon, we used the double bal- loon endoscopy. We observed erythrogenic mucosa of the CASE PRESENTATION ileum resembling salmon roe (Fig. 1b), and the cecum was sup- pressed from the outside. Biopsy was taken from the RS and ileum, A 30-year-old woman underwent left ovariectomy and right but the pathological result was benign. Endoscopic ultrasound ovarian endometrioma resection. At 40 years old, she noticed Received: December 18, 2017. Accepted: February 14, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact firstname.lastname@example.org Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy034/4915334 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 N. Mizuta et al. (b) (a) Figure 1: (a) Endoscopic ﬁndings of RS: A SMT-like lesion was observed. (b) Endoscopic ﬁndings of ileocecum: A salmon roe-like formation of erythrogenic mucosa at the ileum end was observed. (a) (b) Figure 2: CT revealed a mass of ileocecum (arrow). guided ﬁne needle aspiration was also performed from the RS, but no abnormal cell were observed. By abdominal CT, a mass lesion was recognized at the ileocecum. No abnormal lesions were recognized at the rectum (Fig. 2). Preoperative diagnosis was tumor of the ileocecum and SMT of the rectum. The patient has a history of hematochezia and abdominal pain during menstruation, and received resection of Figure 3: (a) Resected specimen (rectum): The serosal dimpling was observed. the endometrioma. Thus, endometriosis was considered as dif- (b) Resected specimen (rectum): A SMT-like lesion was observed. ferential diagnosis. Deﬁnitive diagnosis could not be conﬁrmed, however, surgery was performed because the symptoms were so severe. DISCUSSION Operative ﬁndings: On lower-midline incision, induration with red serosal dimpling was observed at the ileocecum. The Endometriosis is a disease where the endmetorium expands same ﬁnding was observed at the RS and upper rectum. The beyond the uterus. As chronic inﬂammation occurs, dysmenor- uterus was enlarged and the right ovary was normal. First, ileo- rhea, pelvic pain and infertility can develop . Endometriosis is cecal resection was performed, then lower-rectum anterior reported in 6–10% of women of reproductive age , with some resection was performed. reports as many as 15% . Endometriosis is classiﬁed in three Specimen: Strong dimpling of the serosa on rectum and ileo- types: peritoneal endometriosis, endometriotic ovarian cysts cecum was recognized (Figs 3a, b and 4a, b). and deeply inﬁltrative endometriosis (DE) . This patient met Pathological ﬁndings: Fibrosis and the ecchymosis were patho- DE group classiﬁcation. By deﬁnition, DE is where lesions inﬁl- logically observed. Endometrial tissue was seen at the muscular trate beyond 5 mm from serosa into muscular layer within the layer indicated ecchymosis. There were no malignant cells or peritoneum. About 10% of endometriosis occurs in the bowel, lymph node metastasis (Fig. 5a, b). 80–90% of reported cases occur in rectum and sigmoid colon [1, Final diagnosis was endometriosis in the bowel, ileocecum 3]. Clinical symptoms are pelvic pain, infertility, menstrual pain, and rectum. The postoperative course was good and the patient constipation, diarrhea, tenesmus and rectal bleeding . was discharged on ninth postoperative day. The patient is now Differential diagnosis includes inﬂammatory bowel disease, on a course of corpus luteum hormone. solitary rectal ulcer syndrome and rectal tumor . For diagnosis Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy034/4915334 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Bowel endometriosis treated with simultaneous ileocecal 3 (a) (b) Figure 4: (a) Resected specimen (ileocecum): Serosal dimpling was also observed. (b) Resected specimen (ileocecum): A SMT-like lesion was also observed. (a) (b) Figure 5: (a) Specimen (rectum): Contractures and ecchymosis were recognized. (b) Specimen (rectum, H.E. staining): Endometrial tissue was found in ecchymosis in muscularis. of endometriosis, presented symptoms and physical ﬁndings was severe, so optimal treatment was surgery. However, this are most important, but transvaginal ultrasonography, barium may not always be the case, depending on severity. It is neces- enema examination and magnetic resonance imaging (MRI) are sary to consider the method of treatment for bowel endometri- also useful [1–3]. In this case, from the characteristic symptoms, osis, such as drug treatment, surgery and whether bowel endometriosis was suspected in differential diagnosis. Effective resection is required. transvaginal ultrasonography depends on the physician’s skill and experience , but other meta-analysis reported that 91% CONFLICT OF INTEREST STATEMENT sensitivity and 98% speciﬁcity . Barium enema examination is also useful in predicting lesions range and depth [3, 4]. The use- None declared. fulness of MRI jelly was also reported . In summary, as other methods vary in usefulness, to correctly FUNDING make diagnosis, it is necessary to retrieve tissue by surgical inter- vention, and laparoscopy is often performed [1–3]. Concerning The authors declare no ﬁnancial or any other type of support. therapy, it is important to remove pain, prevent recurrence and keep fertility. Surgery is said to be effective in resolving symp- REFERENCES toms such as pain [2, 6]. It is very important to completely remove endometrial tissue by surgery [1–3]. Laparoscopy is reported to 1. Ono H, Honda S, Danjo Y, Nakamura K, Okabe M, Kimura T, have fewer postoperative complications and superior fertility et al. Rectal obstruction due to endometriosis: a case report retention, but there are also reports stating no difference in and review of the Japanese literature. Int J Surg Case Rep 2014; improvement of pain and quality of life . 5:845–8. In the present case, the patient required operation for endo- 2. Dunselman GAJ, Vermeulen N, Becker C, Calhaz-Jorge C, metrioma, so laparotomy was performed to remove the lesion D’Hooghe T, De Bie B, et al. ESHRE guideline: management of completely. There are several methods of lesion resection, such women with endometriosis. Hum Reprod 2014;29:400–12. as discotic resection, intestinal partial resection and resection 3. Albert MW, Christel M, Carla T, Thomas D, Anthony de B, by CO laser [2, 3, 6, 8]. 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Journal of Surgical Case Reports – Oxford University Press
Published: Feb 1, 2018
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