Unusual Bowel Perforation Following Dilatation and Curettage in a Case of Endometrial Cancer

Unusual Bowel Perforation Following Dilatation and Curettage in a Case of Endometrial Cancer We present an unusual case of iatrogenic small bowel perforation in a woman with endometrial cancer. A 57-year-old postmenopausal woman with past history of total colostomy with loop ileostomy for ulcerative colitis, was referred to our department for evaluation and further management of suspected endometrial cancer following dilatation and curettage (D&C) elsewhere. The histopathology showed intestinal element which was attributed to metaplasia; however, no malignancy was identified in the biopsy specimen. Imaging carried out elsewhere after D&C showed thickened endo- metrium with suspicious small bowel infiltration. The patient was completely asymptomatic with no signs of bowel injury or peritonitis. After a complete evaluation, a class 1 extrafascial hysterectomy and bilateral salpingo-oophorectomy with segmental ileal resection and anastomosis and frozen section were performed. Intraoperatively, small bowel loop was found adherent to the posterior uterine wall extending up to the cervix with no obvious sign of any uterine or bowel perforation. The final histopathology revealed endometrioid adenocarcinoma grade 1, stage IA, with tumor located at the fundus along with cervical isthmic perforation on the posterolateral wall with full thickness ileum perforation. Uterine perforation at D&C is a known complication, but a silent bowel injury presenting with intestinal tissue in endometrial biopsy is very unusual. A high degree of suspicion is required to detect such complications at D&C especially in postmenopausal women with past history of abdominal surgery. Keywords Dilatation and curettage (D&C)  Bowel injury  Intestinal element in histopathology  Endometrial cancer Introduction approximately 0.3% in premenopausal woman and 2.6% in the postmenopausal woman [3]. Out of all complications, Endometrial biopsy is a routine and safe surgical procedure full thickness bowel perforation after D&C is a unique and in gynecology. Complications are rare but can be fatal at serious complication, but asymptomatic cases are very rare times [1]. Uterine perforation can occur during D&C by [4, 5]. Diagnosis is by strong a clinical suspicion, and the sounding the uterus or during the cervical dilatation [2]. need for immediate surgical intervention is based on clin- Perforation can also occur during curettage especially in ical signs and symptoms of peritonitis and imaging [6]. We case of previous uterine scar or in the presence of report a unique case of silent iatrogenic ileal perforation in endometrial carcinoma causing weakness in the uterine a case of postmenopausal woman with endometrial wall making it amenable to perforation. During D&C for carcinoma. non-obstetric reasons, perforation has been reported in Case Report & K. Samita Bhat samitasundeep@gmail.com A 57-year-old postmenopausal woman, P1L1, with previ- ous spontaneous vaginal delivery presented with post- Manipal Comprehensive Cancer Centre, Department of Surgical Oncology, Manipal Hospitals, #98, HAL Airport menopausal bleeding at a city hospital. She had a past Road, Bangalore 560017, India history of total colectomy and permanent ileostomy Department of Pathology, Manipal Hospitals, HAL Airport 15 years back for ulcerative colitis. An ultrasound Road, Bangalore, India 123 24 Page 2 of 3 Indian Journal of Gynecologic Oncology (2018) 16:24 abdomen was done which showed thickened endometrium (12 mm) with no other significant findings. She was then planned for hysteroscopy and D&C at the same hospital. Intraoperatively, hysteroscopy was abandoned due to cer- vical stenosis, but D&C with polypectomy was done, and she got discharged in a stable condition on the same day. HPE reported as bits of small intestinal tissue in full thickness with mucosa and some endocervical but no endometrial tissue (Fig. 1). Intestinal element was attrib- uted to metaplasia. Pelvic scan (TVS) on 10th post-D&C day shows thick (2.4 cm) echogenic highly vascular endometrium, irregular junctional zone with myometrial invasion up to the serosa suggestive of endometrial carcinoma. CECT and MRI performed elsewhere reported a normal- sized uterus with endometrial thickness of 2.8 cm. A breach in the junctional zone and myometrium infiltrated posterosuperiorly on the right side with minimal extension of thickened endometrium beyond the uterine serosa was Fig. 2 MRI pelvis sagittal view seen to involve the wall of adjacent ileal loop with intact cervix, raised the possibility of intestinal infiltration of (SLNB) were performed. Segmental ileal resection and endometrial carcinoma (Fig. 2). anastomosis was performed in view of dense adhesions. Patient presented to us 30 days post-D&C with all Frozen section reported as endometrioid adenocarci- reports of investigations. She was completely asymp- noma G2, with \ 50% myometrial invasion and tumor size tomatic on examination. Performance score (ECOG) was of 5 9 3.5 cm with reactive nodes. In view of negative zero, vitals were stable, and abdomen was soft, non-tender sentinel nodes, further staging lymphadenectomy was with no sign of peritonitis. After reviewing the slides, abandoned. The final histopathology showed the same patient was planned for staging laparotomy and frozen findings. Sections from the adherent ileal loop showed section, in view of radiological suspicion of endometrial numerous congested blood vessels in the subepithelium and carcinoma. On laparotomy, dense inter-loop adhesions no evidence of dysplasia/malignancy at the perforation site. between small bowel and to anterior abdominal wall were Sections from the perforated area on in the cervix revealed seen. An ileal segment was densely adherent to the pos- a sinus tract in the cervical epithelium and intense granu- terior wall of uterus extending right from fundus to the lation tissue. No sign of any dysplasia or malignancy was cervix. Rest of the abdomen and ileostomy site on right found at the perforation site (Fig. 3). side appeared healthy. Ileal loop was dissected off the uterine wall by sharp dissection except posteriorly at the level of cervix. Class 1 Hysterectomy and BSO with indocyanine (ICG)-based sentinel lymph node biopsy cervical glands Small bowel Cervical tissue Tissue Sinus tract Fig. 1 D&C specimen showing small bowel villous tissue lying beside the squamous component of cervical tissue Fig. 3 Final HPE reported sinus tract post-D&C in cervical wall 123 Indian Journal of Gynecologic Oncology (2018) 16:24 Page 3 of 3 24 removed should be examined carefully for unusual Discussion appearance before sending the specimen for histopathol- ogy. Management of postmenopausal uterine perforation Uterine perforation is a potential complication of D&C and would depend upon symptoms, signs, and findings on may be associated with injury to viscera (bladder, bowel) [7]. imaging. However, in rare instances like this case, where Factors that make access to the endometrial cavity difficult, intestinal luminal tissue is seen in endometrial curettage e.g., cervical stenosis, or that alter the strength of the sample, possibility of bowel injury should be considered myometrial wall, e.g., pregnancy, lactation, and menopause, rather than attributing it to metaplasia. are the risk factors for uterine or bowel perforation [8]. Hafler et al. retrospectively analyzed the incidence of complications after D&C in non-obstetric uterus in 5329 cases and found that site of uterine perforation was fundus in 47 cases and Compliance with Ethical Standards cervical perforation in three cases and concluded that a retroverted uterus, postmenopausal status, and nulliparity are Conflict of interest Authors declare that they have no conflict of independent risk factors for intraoperative complications [9]. interest. In our case, the presence of intestinal tissue in D&C Open Access This article is distributed under the terms of the Creative specimen raised the following possibilities: (1) In view of Commons Attribution 4.0 International License (http://creative imaging showing suspected bowel infiltration, there was a commons.org/licenses/by/4.0/), which permits unrestricted use, dis- possibility of endometrial cancer perforating the adjacent tribution, and reproduction in any medium, provided you give bowel. However, the biopsy was negative for malignancy. appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were (2) Previous surgery was for ulcerative colitis causing ileo- made. uterine fistula, but there was an absence of intestinal contents draining through the cervix or collecting in the uterus. (3) Uterine perforation was performed during D&C, but patient References was completely asymptomatic for the last 20 days starting from the date of D&C till she approached us. Intraopera- 1. Abulafia O, Shah T, Salame G, Economos K, Serur E, Zinn H, Sokolovkski M, Sherer DM. Sonographic and magnetic reso- tively, also there were no definite signs of perforation. nance imaging findings of pelvic abscess following uterine per- Hence, none of these could be confirmed preoperatively, and foration sustained during office endometrial sampling. J Clin the final diagnosis of bowel perforation and endometrial Ultrasound. 2011;39(5):283–6. cancer was made only by histological evaluation of the 2. McELIN TW, Bird CC, Reeves BD, Scott RC. Diagnostic surgical specimen. That clearly indicates that the perforation dilatation and curettage: a 20-year survey. Obstet Gynecol. 1969;33(6):807–12. was iatrogenic and most probably due to postmenopausal 3. Dunner PS, Thomas MA, Ferreras M, Jerome M. Intrauterine stenosed internal cervical os and distorted cervical canal. incarcerated bowel following uterine perforation during an The learning points in this case are as follows. We should abortion: a case report. Am J Obstet Gynecol. always have a strong suspicion of cervical stenosis in post- 1983;147(8):969–70. 4. Vecchio R, Marchese S, Leanza V, Leanza A, Intagliata E. menopausal women. In this case, as hysteroscopy was not Totally laparoscopic repair of an ileal and uterine iatrogenic possible, an option would have been to do a pipelle biopsy. perforation secondary to endometrial curettage. Int Surg. Another method described is to give prostaglandin analog 2015;100(2):244–8. (PGE1) at least 2 h prior to hysteroscopy and D&C for cer- 5. Coughlin LM, Sparks DA, Chase DM, Smith J. Incarcerated small bowel associated with elective abortion uterine perforation. vical priming and dilatation to avoid perforation [10]. Sec- J Emerg Med. 2013;44(3):e303–6. ondly, bowel perforation should be suspected when yellow 6. Zissin R, Osadchy A, Gayer G. Abdominal CT findings in small fleshy material is curetted along with the endometrium and bowel perforation. Br J Radiol. 2009;82(974):162–71. when patient complains of sudden pain and dragging sensation 7. Gentile GP, Siegler AM. Inadvertent intestinal biopsy during laparoscopy and hysteroscopy: a report of two cases. Fertil Steril. which is often ignored thinking that it is procedure-related 1981;36(3):402–4. pain. In our case though the patient was asymptomatic, but 8. Shulman SG, Bell CL, Hampf FE. Uterine perforation and small because of a previous history of colectomy with along with bowel incarceration: sonographic and surgical findings. Emerg Radiol. 2006;13(1):43–5. suspicion of endometrial carcinoma, a laparotomy was done. 9. Hefler L, Lemach A, Seebacher V, Polterauer S, Tempfer C, Reinthaller A. The intraoperative complication rate of nonob- stetric dilation and curettage. Obstet Gynecol. Conclusion 2009;113(6):1268–71. 10. Zhuo Z, Yu H, Jiang X. A systematic review and meta-analysis of randomized controlled trials on the effectiveness of cervical In a postmenopausal woman with previous bowel or uterine ripening with misoprostol administration before hysteroscopy. Int surgery, extra caution should be exercised during dilatation J Gynecol Obstet. 2016;132(3):272–7. and curettage. The endometrial curetting or any polyp http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Indian Journal of Gynecologic Oncology Springer Journals

Unusual Bowel Perforation Following Dilatation and Curettage in a Case of Endometrial Cancer

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Abstract

We present an unusual case of iatrogenic small bowel perforation in a woman with endometrial cancer. A 57-year-old postmenopausal woman with past history of total colostomy with loop ileostomy for ulcerative colitis, was referred to our department for evaluation and further management of suspected endometrial cancer following dilatation and curettage (D&C) elsewhere. The histopathology showed intestinal element which was attributed to metaplasia; however, no malignancy was identified in the biopsy specimen. Imaging carried out elsewhere after D&C showed thickened endo- metrium with suspicious small bowel infiltration. The patient was completely asymptomatic with no signs of bowel injury or peritonitis. After a complete evaluation, a class 1 extrafascial hysterectomy and bilateral salpingo-oophorectomy with segmental ileal resection and anastomosis and frozen section were performed. Intraoperatively, small bowel loop was found adherent to the posterior uterine wall extending up to the cervix with no obvious sign of any uterine or bowel perforation. The final histopathology revealed endometrioid adenocarcinoma grade 1, stage IA, with tumor located at the fundus along with cervical isthmic perforation on the posterolateral wall with full thickness ileum perforation. Uterine perforation at D&C is a known complication, but a silent bowel injury presenting with intestinal tissue in endometrial biopsy is very unusual. A high degree of suspicion is required to detect such complications at D&C especially in postmenopausal women with past history of abdominal surgery. Keywords Dilatation and curettage (D&C)  Bowel injury  Intestinal element in histopathology  Endometrial cancer Introduction approximately 0.3% in premenopausal woman and 2.6% in the postmenopausal woman [3]. Out of all complications, Endometrial biopsy is a routine and safe surgical procedure full thickness bowel perforation after D&C is a unique and in gynecology. Complications are rare but can be fatal at serious complication, but asymptomatic cases are very rare times [1]. Uterine perforation can occur during D&C by [4, 5]. Diagnosis is by strong a clinical suspicion, and the sounding the uterus or during the cervical dilatation [2]. need for immediate surgical intervention is based on clin- Perforation can also occur during curettage especially in ical signs and symptoms of peritonitis and imaging [6]. We case of previous uterine scar or in the presence of report a unique case of silent iatrogenic ileal perforation in endometrial carcinoma causing weakness in the uterine a case of postmenopausal woman with endometrial wall making it amenable to perforation. During D&C for carcinoma. non-obstetric reasons, perforation has been reported in Case Report & K. Samita Bhat samitasundeep@gmail.com A 57-year-old postmenopausal woman, P1L1, with previ- ous spontaneous vaginal delivery presented with post- Manipal Comprehensive Cancer Centre, Department of Surgical Oncology, Manipal Hospitals, #98, HAL Airport menopausal bleeding at a city hospital. She had a past Road, Bangalore 560017, India history of total colectomy and permanent ileostomy Department of Pathology, Manipal Hospitals, HAL Airport 15 years back for ulcerative colitis. An ultrasound Road, Bangalore, India 123 24 Page 2 of 3 Indian Journal of Gynecologic Oncology (2018) 16:24 abdomen was done which showed thickened endometrium (12 mm) with no other significant findings. She was then planned for hysteroscopy and D&C at the same hospital. Intraoperatively, hysteroscopy was abandoned due to cer- vical stenosis, but D&C with polypectomy was done, and she got discharged in a stable condition on the same day. HPE reported as bits of small intestinal tissue in full thickness with mucosa and some endocervical but no endometrial tissue (Fig. 1). Intestinal element was attrib- uted to metaplasia. Pelvic scan (TVS) on 10th post-D&C day shows thick (2.4 cm) echogenic highly vascular endometrium, irregular junctional zone with myometrial invasion up to the serosa suggestive of endometrial carcinoma. CECT and MRI performed elsewhere reported a normal- sized uterus with endometrial thickness of 2.8 cm. A breach in the junctional zone and myometrium infiltrated posterosuperiorly on the right side with minimal extension of thickened endometrium beyond the uterine serosa was Fig. 2 MRI pelvis sagittal view seen to involve the wall of adjacent ileal loop with intact cervix, raised the possibility of intestinal infiltration of (SLNB) were performed. Segmental ileal resection and endometrial carcinoma (Fig. 2). anastomosis was performed in view of dense adhesions. Patient presented to us 30 days post-D&C with all Frozen section reported as endometrioid adenocarci- reports of investigations. She was completely asymp- noma G2, with \ 50% myometrial invasion and tumor size tomatic on examination. Performance score (ECOG) was of 5 9 3.5 cm with reactive nodes. In view of negative zero, vitals were stable, and abdomen was soft, non-tender sentinel nodes, further staging lymphadenectomy was with no sign of peritonitis. After reviewing the slides, abandoned. The final histopathology showed the same patient was planned for staging laparotomy and frozen findings. Sections from the adherent ileal loop showed section, in view of radiological suspicion of endometrial numerous congested blood vessels in the subepithelium and carcinoma. On laparotomy, dense inter-loop adhesions no evidence of dysplasia/malignancy at the perforation site. between small bowel and to anterior abdominal wall were Sections from the perforated area on in the cervix revealed seen. An ileal segment was densely adherent to the pos- a sinus tract in the cervical epithelium and intense granu- terior wall of uterus extending right from fundus to the lation tissue. No sign of any dysplasia or malignancy was cervix. Rest of the abdomen and ileostomy site on right found at the perforation site (Fig. 3). side appeared healthy. Ileal loop was dissected off the uterine wall by sharp dissection except posteriorly at the level of cervix. Class 1 Hysterectomy and BSO with indocyanine (ICG)-based sentinel lymph node biopsy cervical glands Small bowel Cervical tissue Tissue Sinus tract Fig. 1 D&C specimen showing small bowel villous tissue lying beside the squamous component of cervical tissue Fig. 3 Final HPE reported sinus tract post-D&C in cervical wall 123 Indian Journal of Gynecologic Oncology (2018) 16:24 Page 3 of 3 24 removed should be examined carefully for unusual Discussion appearance before sending the specimen for histopathol- ogy. Management of postmenopausal uterine perforation Uterine perforation is a potential complication of D&C and would depend upon symptoms, signs, and findings on may be associated with injury to viscera (bladder, bowel) [7]. imaging. However, in rare instances like this case, where Factors that make access to the endometrial cavity difficult, intestinal luminal tissue is seen in endometrial curettage e.g., cervical stenosis, or that alter the strength of the sample, possibility of bowel injury should be considered myometrial wall, e.g., pregnancy, lactation, and menopause, rather than attributing it to metaplasia. are the risk factors for uterine or bowel perforation [8]. Hafler et al. retrospectively analyzed the incidence of complications after D&C in non-obstetric uterus in 5329 cases and found that site of uterine perforation was fundus in 47 cases and Compliance with Ethical Standards cervical perforation in three cases and concluded that a retroverted uterus, postmenopausal status, and nulliparity are Conflict of interest Authors declare that they have no conflict of independent risk factors for intraoperative complications [9]. interest. In our case, the presence of intestinal tissue in D&C Open Access This article is distributed under the terms of the Creative specimen raised the following possibilities: (1) In view of Commons Attribution 4.0 International License (http://creative imaging showing suspected bowel infiltration, there was a commons.org/licenses/by/4.0/), which permits unrestricted use, dis- possibility of endometrial cancer perforating the adjacent tribution, and reproduction in any medium, provided you give bowel. However, the biopsy was negative for malignancy. appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were (2) Previous surgery was for ulcerative colitis causing ileo- made. uterine fistula, but there was an absence of intestinal contents draining through the cervix or collecting in the uterus. (3) Uterine perforation was performed during D&C, but patient References was completely asymptomatic for the last 20 days starting from the date of D&C till she approached us. Intraopera- 1. Abulafia O, Shah T, Salame G, Economos K, Serur E, Zinn H, Sokolovkski M, Sherer DM. Sonographic and magnetic reso- tively, also there were no definite signs of perforation. nance imaging findings of pelvic abscess following uterine per- Hence, none of these could be confirmed preoperatively, and foration sustained during office endometrial sampling. J Clin the final diagnosis of bowel perforation and endometrial Ultrasound. 2011;39(5):283–6. cancer was made only by histological evaluation of the 2. McELIN TW, Bird CC, Reeves BD, Scott RC. Diagnostic surgical specimen. That clearly indicates that the perforation dilatation and curettage: a 20-year survey. Obstet Gynecol. 1969;33(6):807–12. was iatrogenic and most probably due to postmenopausal 3. Dunner PS, Thomas MA, Ferreras M, Jerome M. Intrauterine stenosed internal cervical os and distorted cervical canal. incarcerated bowel following uterine perforation during an The learning points in this case are as follows. We should abortion: a case report. Am J Obstet Gynecol. always have a strong suspicion of cervical stenosis in post- 1983;147(8):969–70. 4. Vecchio R, Marchese S, Leanza V, Leanza A, Intagliata E. menopausal women. In this case, as hysteroscopy was not Totally laparoscopic repair of an ileal and uterine iatrogenic possible, an option would have been to do a pipelle biopsy. perforation secondary to endometrial curettage. Int Surg. Another method described is to give prostaglandin analog 2015;100(2):244–8. (PGE1) at least 2 h prior to hysteroscopy and D&C for cer- 5. Coughlin LM, Sparks DA, Chase DM, Smith J. Incarcerated small bowel associated with elective abortion uterine perforation. vical priming and dilatation to avoid perforation [10]. Sec- J Emerg Med. 2013;44(3):e303–6. ondly, bowel perforation should be suspected when yellow 6. Zissin R, Osadchy A, Gayer G. Abdominal CT findings in small fleshy material is curetted along with the endometrium and bowel perforation. Br J Radiol. 2009;82(974):162–71. when patient complains of sudden pain and dragging sensation 7. Gentile GP, Siegler AM. Inadvertent intestinal biopsy during laparoscopy and hysteroscopy: a report of two cases. Fertil Steril. which is often ignored thinking that it is procedure-related 1981;36(3):402–4. pain. In our case though the patient was asymptomatic, but 8. Shulman SG, Bell CL, Hampf FE. Uterine perforation and small because of a previous history of colectomy with along with bowel incarceration: sonographic and surgical findings. Emerg Radiol. 2006;13(1):43–5. suspicion of endometrial carcinoma, a laparotomy was done. 9. Hefler L, Lemach A, Seebacher V, Polterauer S, Tempfer C, Reinthaller A. The intraoperative complication rate of nonob- stetric dilation and curettage. Obstet Gynecol. Conclusion 2009;113(6):1268–71. 10. Zhuo Z, Yu H, Jiang X. A systematic review and meta-analysis of randomized controlled trials on the effectiveness of cervical In a postmenopausal woman with previous bowel or uterine ripening with misoprostol administration before hysteroscopy. Int surgery, extra caution should be exercised during dilatation J Gynecol Obstet. 2016;132(3):272–7. and curettage. The endometrial curetting or any polyp

Journal

Indian Journal of Gynecologic OncologySpringer Journals

Published: Apr 13, 2018

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