Bowel endometriosis treated with simultaneous ileocecal and rectal resection

Bowel endometriosis treated with simultaneous ileocecal and rectal resection 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 [1]. It occurs in right-side chest and back pain during menstruation so visited ~6–10% of the females of reproductive age [1]. 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 journals.permissions@oup.com 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 [2]. Endometriosis is cecal resection was performed, then lower-rectum anterior reported in 6–10% of women of reproductive age [1], with some resection was performed. reports as many as 15% [3]. 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) [3]. 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 [3]. 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 [3]. 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 [2], but other meta-analysis reported that 91% CONFLICT OF INTEREST STATEMENT sensitivity and 98% specificity [4]. 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 [5]. 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 [7]. 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]. But, if the resection range extends to Andre D’H. Bowel endometriosis: colorectal surgeon’s perspec- over half of the intestinal tract, total intestinal resection is tive in a multidisciplinary surgical team. World J Gastroenterol necessary [3]. In this case, the lesion extended to over half of 2014;20:15616–23. the tract and stenosis was doubted, so intestinal resection was 4. Hudelist G, English J, Thomas AE, Tinelli A, Singer CF, performed on both the ileocecum and rectal lesion. The recur- Keckstein J. Diagnostic accuracy of transvaginal ultrasound rence rate of endometriosis in patients receiving intestinal for non invasive diagnosis of bowel endometriosis: system- resection is reported between 4.7 and 25% with follow up over 2 atic review and meta analysis. Ultrasound Obstet Gynecol 2011; years [6]. 37:257–63. We encountered a very rare case of bowel endometriosis in 5. Takeuchi H, KuwatsuruR,Kitade M,Sakurai A, KikuchiI, both the ileocecum and the rectum at the same time. Our case Shimanuki H, et al. A novel technique using magnetic resonance Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy034/4915334 by Ed 'DeepDyve' Gillespie user on 16 March 2018 4 N. Mizuta et al. imaging jelly for evaluation of rectovaginal endometriosis. colorectal resection for endometriosis. Morbidity, symptoms, Fertil Steril 2005;83:442–7. quality of life, and fertility. Ann Surg 2010;251:1018–23. 6. Christel M, Carla T, Andre D, Ben VC, Freddy P, Igna V, et al. 8. Christel M, Carl T, Albert W, Ben VC, Annouschka L, Freddy Surgical treatment of deeply infiltrating endometriosis with P, et al. Clinical outcome after radical excision of moderate- colorectal involvement. Hum Reprod Update 2011;17:311–26. severe endometriosis with or without bowel resection and 7. Emile D, Gil D, Charles C, Catherine F, Roman R, Marcos B. reanastmosis. A prospective cohort study. Ann Surg 2014;259: Randomized trial of laparoscopically assisted versus open 522–31. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy034/4915334 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Bowel endometriosis treated with simultaneous ileocecal and rectal resection

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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
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Abstract

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 [1]. It occurs in right-side chest and back pain during menstruation so visited ~6–10% of the females of reproductive age [1]. 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 journals.permissions@oup.com 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 [2]. Endometriosis is cecal resection was performed, then lower-rectum anterior reported in 6–10% of women of reproductive age [1], with some resection was performed. reports as many as 15% [3]. 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) [3]. 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 [3]. 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 [3]. 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 [2], but other meta-analysis reported that 91% CONFLICT OF INTEREST STATEMENT sensitivity and 98% specificity [4]. 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 [5]. 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 [7]. 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]. But, if the resection range extends to Andre D’H. Bowel endometriosis: colorectal surgeon’s perspec- over half of the intestinal tract, total intestinal resection is tive in a multidisciplinary surgical team. World J Gastroenterol necessary [3]. In this case, the lesion extended to over half of 2014;20:15616–23. the tract and stenosis was doubted, so intestinal resection was 4. Hudelist G, English J, Thomas AE, Tinelli A, Singer CF, performed on both the ileocecum and rectal lesion. The recur- Keckstein J. Diagnostic accuracy of transvaginal ultrasound rence rate of endometriosis in patients receiving intestinal for non invasive diagnosis of bowel endometriosis: system- resection is reported between 4.7 and 25% with follow up over 2 atic review and meta analysis. Ultrasound Obstet Gynecol 2011; years [6]. 37:257–63. We encountered a very rare case of bowel endometriosis in 5. Takeuchi H, KuwatsuruR,Kitade M,Sakurai A, KikuchiI, both the ileocecum and the rectum at the same time. Our case Shimanuki H, et al. A novel technique using magnetic resonance Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy034/4915334 by Ed 'DeepDyve' Gillespie user on 16 March 2018 4 N. Mizuta et al. imaging jelly for evaluation of rectovaginal endometriosis. colorectal resection for endometriosis. Morbidity, symptoms, Fertil Steril 2005;83:442–7. quality of life, and fertility. Ann Surg 2010;251:1018–23. 6. Christel M, Carla T, Andre D, Ben VC, Freddy P, Igna V, et al. 8. Christel M, Carl T, Albert W, Ben VC, Annouschka L, Freddy Surgical treatment of deeply infiltrating endometriosis with P, et al. Clinical outcome after radical excision of moderate- colorectal involvement. Hum Reprod Update 2011;17:311–26. severe endometriosis with or without bowel resection and 7. Emile D, Gil D, Charles C, Catherine F, Roman R, Marcos B. reanastmosis. A prospective cohort study. Ann Surg 2014;259: Randomized trial of laparoscopically assisted versus open 522–31. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy034/4915334 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Journal of Surgical Case ReportsOxford University Press

Published: Feb 1, 2018

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