World Journal of Medical and Surgical Case Reports Volume No 6

Correspondence Open Access

Endometriosis of the Sigmoid Colon Presenting as Acute Intestinal Obstruction

Vitorino Modesto dos Santos

Adjunct-professor of Internal Medicine, Armed Forces Hospital and Catholic University of Brasília, Brasília-DF, Brazil.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

  • Submitted: Friday, February 3, 2017
  • Accepted: Friday, March 31, 2017
  • Published: Saturday, April 22, 2017
  • Abstract

    Endometriosis is a relatively frequent condition, but the intestinal involvement is uncommon and evolves asymptomatic in up to 37% of cases, whereas complete obstruction rarely occurs. Two case studies of intestinal bowel obstruction due to endometriosis are herein commented, with emphasis about the diagnostic challenges related to abdominal malignant conditions.

    Key Words

    endometriosis, bowel endometriosis, intestinal obstruction

    Dear Editor,

    Endometriosis is a common abdominal condition that may cause clinical diagnostic challenges. Intestinal involvement occurs in 12-37% of cases, mainly restricted to the serosa surfaces; so, total obstructions are scarcely reported and intestinal resections are very rarely performed [1, 2]. Symptoms and images are unspecific, and the diagnosis depends on surgical procedures [1, 2]. I read with interest the case study recently published in this Journal by Der E M et al., [1]. The 30-year-old nulliparous patient had severe dysmenorrhea and denied contraceptive usage. She presented with acute abdomen due to total obstruction of the sigmoid colon by endometriosis. Worthy of note, the constricting tumor mimicked features of sigmoid colon carcinoma because the endometrial glands and stroma involved the muscular wall and the submucosa of the bowel, whereas the serosa membrane and the mucosa layer were preserved [1]. A major concern about colon malignancy was the lack of involvement of the serosa surface and 21 lymph nodes detected in the pericolic fat [1]. The authors emphasized that the left sigmoid colectomy was performed due to the presumptive initial diagnosis of carcinoma of the sigmoid colon, which would be the cause of the acute intestinal obstruction [1]. They highlighted the diagnostic challenges posed by endometriosis mimicking carcinoma, till the histopathological analysis of tumor and lymph nodes ruled out the hypothesis of malignancy.

    Their case report is illustrative about possible pre-operative and intraoperative pitfalls involving large bowel endometriosis, and the role of invasive procedures to establish the correct diagnosis [1]. Endometriosis is common in the reproductive age group and intestinal involvement, more often asymptomatic, occurs in up to 37% of cases, with total obstruction in less than 1% [1]. Additional comments should be done about a 40-year-old nulliparous woman with ovarian endometriosis, massive ascites, and small bowel obstruction described by Santos VM et al., [2]. Laparoscopy showed a cocoon-like thickened peritoneum encasing the small intestinal loops. Histopathology study of biopsy samples showed intense fibrosis in the peritoneum involving endometrial glands and vessels, fat cells, mononuclear infiltrates and giant cell granuloma [2]. These are classical findings described in encapsulating peritonitis or abdominal cocoon [2]. Different from the findings of Der EM et al., endometriosis was limited to the serosa surface and episodes of intestinal obstruction were not due to occlusion of the lumen by the tumor. The cause was a dense peritoneal membrane, which encased the small bowel loops; whereas the main diagnostic concern was about a primary ovarian cancer with peritoneal metastases. Notwithstanding, the histopathological evaluation discarded the hypothesis of malignancy [2]. As a whole, the reported cases well demonstrate diagnostic challenges related to intestinal endometriosis, mainly because of propensity to mimic abdominal malignant conditions [1,2].

    Although with inherent limitations of simple case studies, the commented manuscripts yielded useful practical examples to enhance the suspicion index of primary health care workers.

    Author Contribution

    SVM: concept and design, preparation of manuscript.

    Conflict of interests

    The authors declare that there are no conflicts of interests.

    Funding

    None declared.

    Ethical Consideration

    This is a correspondence on published cases

    References

    1. Der EM, Quayson SE, Tetteh A, Simon B, Naaeder SB. Endometriosis of the sigmoid colon presenting as acute intestinal obstruction: a case report. World J Med Surg Case Rep 2015;4:51-4. [Free Full text].
    2. Santos VM, Barbosa Junior ER, Lima SHM, Porto AS. Abdominal cocoon associated with endometriosis. Singapore Med J 2007;48:e240-2. [PubMed]. [Free Full text]