Endoscopic diagnosis of colonic endometriosis.

Involvement of the colon or rectum with endometriosis is uncommon but may be a cause of gastrointestinal symptoms such as diarrhea, pain, and bleeding. To determine whether endoscopy has a role in evaluating endometriosis of the colon, we reviewed all cases of endometriosis undergoing colonic resection from 1984 to 1989. There were nine patients, six of whom had intermittent hematochezia. All had lesions detected at endoscopy described as a polyp, mass, or stricture. Five of the six patients with symptoms of hematochezia had mucosal involvement in the resected specimen. Four of these five had a visible lesion at endoscopy with endometriosis on biopsy. The three patients without hematochezia had no mucosal endometriosis in the resected colonic specimen or endometrial tissue on biopsy. In patients with colonic endometriosis and hematochezia, endoscopy and biopsy can confirm the diagnosis of colonic endometriosis.     

A Case of Endometriosis of the Appendix

A 51-year-old woman visited our clinic her chief complaint being right hypogastric discomfort. An abdominal ultrasonography revealed a circular, cystic mass in the right hypogastric region. A colorectal radiography disclosed a semi-globular shadow defect at the end of the cecum and did not visualize the appendix. A colorectal endoscopy revealed a submucosal tumor accompanied by a central dimple which seemed to represent the ostium appendicis vermiformis. Based on a preoperative diagnosis of submucosal tumor, the patient underwent a partial resection of the cecum. A histopathological examination of tissue removed led to a diagnosis of endometriosis of the appendix. In Japan, 7 cases of endometriosis of the appendix have been reported to date. In those cases, endometriosis of the appendix was detected as a lesion accompanying endometriosis of some other site or during laparotomy was based on a diagnosis of acute appendicitis. Unlike these cases, the patient presented here had been diagnosed by a preoperative colorectal radiography and endoscopy as having a submucosal tumor of the appendix.     

Intrahepatic endometriosis as differential diagnosis: Case report and literature review

Intrahepatic endometriosis is one of the rarest forms of atypical endometriosis; only eighteen cases have been reported in the English literature. We describe the case of a 32-year-old woman, who presented with persistent, non-cyclical upper right quadrant abdominal pain, a central liver cyst, and no history of endometriosis. Three years previous, she was diagnosed with an intrahepatic cyst. The lesion progressed and two laparoscopic deroofing-operations were performed, yet the diagnosis of intrahepatic endometriosis was never reached. She presented in our clinic with further progress of the cyst as well as obstruction of the intrahepatic biliary system. The magnetic resonance imaging showed a 9.5 cm × 12 cm, lobulated intrahepatic cyst. We performed an ultrasonic pericystectomy. Immunostaining confirmed intrahepatic endometriosis. Only one of the previously described eighteen patients with intrahepatic endometriosis presented with cyclical pain in the upper right abdominal quadrant accompanying menstruation. This lack of a "typical" clinic makes it challenging to diagnose extragonadal endometriosis without histopathology. A previous history of endometriosis was described in only twelve cases, thus the diagnosis of this condition should not be limited to patients with a known history of endometriosis. Six of 18 patients were postmenopausal, demonstrating this condition is not limited to women of reproductive age. A preoperative diagnosis was only reached in seven of the previously described cases, highlighting the importance of preoperative biopsies. Yet due to the potential adverse effects, a transhepatic biopsy must be discussed individually. Although rare, intrahepatic endometriosis should always be considered as a differential diagnosis in women with recurrent hepatic cysts, regardless of age or previous medical history. In such cases, histology is essential and a pericystectomy should be performed as standard of care.     

Deciduosis of the Appendix During Pregnancy

Acute appendicitis is an important differential diagnosis in patients with right lower quadrant pain during pregnancy. Endometriosis, a hormone-related pathology, is another possibility. Patients with endometriosis are typically symptomatic before pregnancy. Stromal endometriosis is a variant of endometriosis that presents no symptoms before pregnancy but which occasionally presents with the new onset of symptoms during pregnancy. We report the case of a 35-year-old woman in her 8th month of pregnancy who presented with impending appendiceal rupture due to deciduosis of the appendix, a progesterone-related condition, during pregnancy. This case suggests that deciduosis/stromal endometriosis should be considered as a differential diagnosis of acute abdomen during pregnancy, even if the patient is asymptomatic before pregnancy.     

A case of secondary amyloidosis presenting as massive gastrointestinal bleeding]

Amyloidosis is a disorder characterized by extracellular deposition of amyloid in various tissues and organs. Gastrointestinal manifestations including gastroparesis, constipation, malabsorption, intestinal pseudo-obstruction, and bleeding are common. GI bleeding is a rare initial symptom which can be fatal in some cases. Absence of systemic symptoms and nonspecific endoscopic findings in amyloidosis may make diagnosis difficult. Therefore, amyloidosis-induced GI bleeding should be considered in patients with an obscure hemorrhage. Recently, we experienced a 65-year-old woman who presented with massive hematochezia as a manifestations of amyloidosis. Colonoscopy and SMA angiography showed massive bleeding in the small and large intestine. Colonoscopic biopsy established amyloidosis. We report this case with a review of the relevant literatures.     

MRI facilitated a diagnosis of endometriosis of the rectum

A 51-year-old pre-menopausal Japanese woman suffering from chronic lower abdominal pain was referred to our hospital. A barium enema showed a stenotic lesion in the recto-sigmoid region, and a pelvic computed axial tomography (CAT) scan revealed a thickened rectal wall. A colonoscopic examination showed the rectum to be constrictive, but the mucosa appeared to be intact. Magnetic resonance imaging (MRI) with T1 high-intensity revealed a cystic lesion in the thickened wall of the rectum, which led us to suspect possible bowel endometriosis. Part of the biopsy specimen showed endometrial epithelium within the interstitial layer of histologically normal mucosa; finally, endometriosis of the rectum was diagnosed. The patient became asymptomatic after the initiation of hormonal treatment and later experienced spontaneous menopause. MRI was effective for diagnosis and the patient did not undergo unnecessary laparotomy. Although bowel endometriosis is generally diagnosed by means of resected specimens, in our patient, diagnosis was made using MRI and biopsy, and hormonal therapy had an effective role as a bridge to menopause. Received: July 12, 1999 / Accepted: January 28, 2000     

Rectovaginal septum endometriosis: a disease with specific diagnosis and treatment

BACKGROUND: The involvement of the rectovaginal septum, of rectum and sigmoid by endometriosis leads to intense symptoms as dysmenorrhea, pelvic pain, deep dyspareunia, tenesmus and hematochezia in young and middle aged women during periods. The diagnosis can be made by tipycal history and vaginal examination, rectal examination, barium enema, proctoscopy and so on. The indications of operation include severe clinic symptoms and failed conservative therapy. The treatment of choice for this type of endometriosis is the surgical resection of affected tissue, in order to relieve patient symptoms, and avoid disease progression. The correct assessment as to the presence and extension of the endometriosis-affected sites such as the rectum, uterosacral ligaments and rectovaginal septum is extremely important to provide better results with the surgical treatment of endometriosis. AIM: To describe the main aspects related to rectovaginal septum endometriosis and offer the general surgeon some information about this enigmatic disease. CONCLUSION: Rectovaginal septum endometriosis is a frequent disease, with specific diagnosis and treatment.     

Ileocecal endometriosis and a diagnosis dilemma: A case report and literature review

Bowel endometriosis affects between 3.8% and 37% of women with endometriosis. The evaluation of symptoms and clinical examination are inadequate for an accurate diagnosis of intestinal endometriosis. We describe the case of a 41-year-old woman who presented to our hospital because of six months of recurrent abdominal pain, vomiting and diarrhea, without previous history of bowel disease. Physical examination revealed a palpable 3 cm × 5 cm mass in the right lower quadrant abdomen. Laboratory tests showed slightly elevated levels of CA19-9 and CA125. Small bowel computer tomography scanning revealed an ileocecal mass with bowel wall thickening and luminal narrowing. Small bowel endoscopy identified a deep longitudinal ulcer and mucosal edema in the distal ileum. All these findings supported the diagnosis of Crohn’s disease. The patient underwent a laparotomy, which identified a 5 cm × 5 cm ileocecal mass with severe mucosal edema and luminal stricture in the distal ileum. Histopathological examination confirmed a diagnosis of ileocecal endometriosis without other areas involved. After oneyear follow-up, there was no recurrence of the symptoms.     

A very rare entity: catamenial pneumothorax

Catamenial pneumothorax, a variant of spontaneous pneumothorax occurs exclusively in women of menstrual age. Catamenial pneumothorax is associated with a high rate of recurrence. The etiology and pathogenesis is enigmatic. We describe the case of a 42-year-old woman with right-sided catamenial pneumothorax recurring four times, caused by ectopic endometriosis in the pleural layers which was confirmed histopathologically. Surgical treatment should be accomplished during menstruation for optimal visualization of pleurodiaphragmatic endometriosis.     

Methamphetamine-induced ischemic colitis.

A 50-year-old woman with acute onset of right lower quadrant pain and hematochezia proved to have segmental ischemic colitis associated with methamphetamine abuse. The diagnosis was established by colonoscopy with biopsy, and abdominal angiography revealed no thrombosis, vasculitis, or vasospasm. The condition resolved within 10 days. Since methamphetamine abuse is increasing, physicians should be aware of its potential to produce intestinal ischemia.     

Colonic ischemia associated with naratriptan use

A 54-year-old woman with acute onset of hematochezia and lower abdominal pain proved to have ischemic colitis associated with the use of naratriptan. The diagnosis was established by colonoscopy with biopsy. There were no other obvious risk factors for intestinal ischemia. The condition resolved within 4 days. Because the use of triptans for the treatment of migraine is increasing, health care providers should be aware of their potential for inducing ischemic colitis.     

Recurrence of catamenial pneumothorax after surgical treatment]

We reported a case of catamenial pneumothorax that was recurrent after surgical treatment. A 43-year-old woman had sudden chest pain and dyspnea during menstruation. Right pneumothorax and pleural effusion were pointed out on chest X-ray films. When the patient was 31 years old, she received a diagnosis of catamenial pneumothorax and underwent thoracotomy for resection of diaphragmatic endometriosis. However, after surgery she experienced recurrence of right pneumothorax, and was accordingly treated with danazol. The patient decided to terminate medication by herself because her symptoms had disappeared. Several years after the cessation of medication, she experienced chest pain frequently during menstruation, but did not seek a medical check-up. She visited our department because of persistent chest pain in 1997. After the patient was hospitalized, pneumothorax was diagnosed and continuous drainage was performed. Although pneumothorax was alleviated by drainage, it recurred during the patient's next menstrual period. Open lung surgery was performed. Diaphragmatic endometriosis with a small hole and inflammatory thickened lesions on the visceral pleura of the lower lobe (S 6) were found and excised. Microscopic examination of the excised specimens showed endometriosis. Visceral pleural endometriosis has been histologically demonstrated in very few cases. After surgery, hormonal therapy was started. The patient has been well for 12 months without recurrence of pneumothorax. Both surgical and hormonal treatment were considered necessary for the treatment of catamenial pneumothorax in this case.     

A typical presentation of a rare cause of obscure gastrointestinal bleeding

A 52-year-old white woman had suffered from intermittent gastrointestinal (GI) bleeding for one year. Upper GI endoscopy, colonoscopy and peroral doubleballoon enteroscopy (DBE) did not detect any bleeding sour ce, suggesting obscure GI bleeding. However, in video capsule endoscopy a jejunal ulceration without blee ding signs was suspected and this was endoscopically conf irmed by another peroral DBE. After transfusion of packed red blood cells, the patient was discharged from our hospital in good general condition.Two weeks later she was readmitted because of another episode of acute bleeding. Multi-detector row computed tomography with 3D reconstruction was performed revealing a jejunal tumor causing lower gastrointestinal bleeding. The patient underwent exploratory laparotomy with partial jejunal resection and end-to-end jejunostomy for reconstruction. Histological examination of the specimen confirmed the diagnosis of a low risk gastrointestinal stromal tumor (GIST). Nine days after surgery the patient was discharged in good health. No signs of gastrointestinal rebleeding occurred in a followup of eight months. We herein describe the comp lex presentation and course of this patient with GIST and also review the current approach to treatm ent.     

Hematochezia due to a renal cell carcinoma metastasis to the rectum: A case report and review of the literature

While primary tumors of the GI tract are a frequent cause of gastrointestinal bleeding, metastatic lesions to the bowel uncommonly present with hematochezia, and rectal involvement is particularly rare. We describe the case of a 70-year-old man with an exceedingly late recurrence of renal cell carcinoma who presented with hematochezia due to a metastasis in the rectum. This is the first report to include both endoscopic and endoscopic ultrasound images of such a lesion. In the correct clinical setting, metastatic disease to the rectum should be included on the differential diagnosis of lower gastrointestinal bleeding.     

Unsuspected ileal stenosis causing obscure GI bleeding in patients with previous abdominal surgery—diagnosis by capsule endoscopy: a report of two cases

Peri-anastomotic ulcerations may occur in patients with previous abdominal surgery. They may present only with obscure GI bleeding. We report two cases in whom capsule endoscopy identified postsurgical stenoses with ulcers as the cause of obscure GI bleeding. Case 1. A 57-year-old male operated on in 1970 for a post-traumatic diaphragm hernia followed by displacement of the caecum in the upper left abdominal quadrant. Case 2. A 32-year-old female with a salpingectomy for tuberculosis (1978) followed by segmental ileal resection for intestinal obstruction. Both patients had undergone extensive work-up including bidirectional endoscopies and enteroclysis with negative results. Capsule endoscopy with the GIVEN diagnostic system was done. Ileal stenoses with mucosal ulcers in dilated prestenotic loops were observed in both cases. The capsule was retained at the stenosis site, requiring ileal resection and anastomosis. Pathology reports showed mucosal ulcers. In case 2, tuberculosis was ruled out by tissue and faecal polymerase chain reaction and culture. Ileal stenoses with prestenotic ulcerations causing GI bleeding may occur in patients with previous abdominal surgery. Capsule endoscopy may clarify the diagnosis and shorten the diagnostic work-up. However, these patients should be warned that capsule retention requiring surgery might occur.     

Pulmonary endometriosis resected by video-assisted thoracoscopic surgery

Catamenial haemoptysis is a rare condition caused by thoracic endometriosis that presents as tracheobronchial or pulmonary endometriosis. The authors report a 31-year-old woman with a 1-year history of catamenial haemoptysis, which was diagnosed by chest CT scan during menses and treated successfully by means of video-assisted thoracoscopic surgery of the solitary pulmonary lesion. There was no evidence of recurrence 6 months after the operation. The authors suggest that video-assisted thoracoscopic surgery is an effective therapy for catamenial haemoptysis caused by localized peripheral pulmonary endometriosis.     

Ileal schwannoma in which blood loss scintigraphy was useful for diagnosis

An 85-year-old woman was hospitalized with severe melena of unknown origin. Upper gastrointestinal (GI) endoscopy and lower GI endoscopy did not detect the origin and we could not establish any diagnosis. To explore the bleeding site, 99mTc-HSA blood loss scintigraphy was performed and a tumor of the small intestine was suspected. Fluoroscopic examination of the small intestine and abdominal CT scan confirmed an ileal tumor measuring 4x3 cm. The mass was a well-demarcated tumor about 80 cm proximal to Bauhin's valve. Partial resection of the ileum was carried out and the tumor was histologically diagnosed as schwannoma. Thereafter, there has been no recurrence of melena nor metastasis of the tumor. It is thought that blood loss scintigraphy is a useful method for unexplained exacerbation of melena.     

Jejunal carcinoid tumor mimicking leiomyosarcoma: preoperative diagnosis by endoscopic biopsy

Primary carcinoid tumor of the jejunum is rare, and is an unusual cause of massive gastrointestinal bleeding. A case of primary jejunal carcinoid tumor in a 39-year-old woman who presented with massive hematochezia is described. Both upper and lower gastrointestinal endoscopies showed no abnormalities. An abdominal computed tomographic scan, small-bowel barium contrast studies, and small-bowel endoscopy showed a subserosal mass, of 5 × 4 cm, with a cavity suggesting central necrosis, and a deep mucosal ulceration, located in the proximal jejunum. Although these clinical presentations were strongly suggestive of a leiomyosarcoma, histologic examination of biopsy samples obtained by enteroscopy confirmed the diagnosis of jejunal carcinoid tumor. The patient underwent radical jejunal resection and recovered uneventfully. In spite of the large size of the tumor, there was one solitary lymph node metastasis, but no evidence of liver metastases. This kind of jejunal carcinoid tumor, presenting with massive gastrointestinal bleeding and a subserosal bulky growth mimicking a leiomyosarcoma, has not been reported previously. Moreover, this is a rare case of a jejunal carcinoid which was diagnosed preoperatively by small bowel-endoscopic biopsy. Received: August 9, 1999 / Accepted: April 28, 2000     

Photodiagnostic techniques for the endoscopic detection of premalignant gastrointestinal lesions

Considerable attention is given to the clinical diagnosis of gastrointestinal (GI) malignancies as they remain the second leading cause of cancer‐associated deaths in developed countries. Detection and intervention at an early stage of preneoplastic development significantly improve patient survival. High‐risk assessment of asymptomatic patients is currently performed by strict endoscopic surveillance biopsy protocols aimed at early detection of dysplasia and malignancy. However, poor sensitivity associated with frequent surveillance programs incorporating conventional screening tools, such as white light endoscopy and multiple random biopsy, is a significant limitation. Recent advances in biomedical optics are illuminating new ways to detect premalignant lesions of the GI tract with endoscopy. The present review presents a summary report on the newest developments in modern GI endoscopy, which are based on novel optical endoscopic techniques: fluorescence endoscopic imaging and spectroscopy, Raman spectroscopy, light scattering spectroscopy, optical coherence tomography, chromoendoscopy, confocal fluorescence endoscopy and immunofluorescence endoscopy. Relying on the interaction of light with tissue, these ‘state‐of‐the‐art’ techniques potentially offer an improved strategy for diagnosis of early mucosal lesions by facilitating targeted excisional biopsies. Furthermore, the prospects of real‐time ‘optical biopsy’ and improved staging of lesions may significantly enhance the endoscopist's ability to detect subtle preneoplastic mucosal changes and lead to curative endoscopic ablation of these lesions. Such advancements within this specialty will be rewarded in the long term with improved patient survival and quality of life.     

Jejunal Dieulafoy lesion with intraintestinal calcification on computerized tomography: A case report

Rationale:A Dieulafoy lesion is a rare cause of gastrointestinal (GI) bleeding, especially in the jejunum, and the presence of calcifications on CT might be suspicious of the diagnosis.Patient concerns:We describe a 72-year-old woman with anemia and melena. Hemoglobin was 6.0 g/dL, and the stools were positive for occult blood (4+). Blood pressure was 116/54 mm Hg. Physical examination showed pale face and pitting edema in both lower limbs. Abdominal computerized tomography showed calcification in the small intestine of the left lower abdomen. Capsule endoscopy showed a blood clot.Diagnoses:Dieulafoy lesion.Interventions:Single balloon endoscopy was performed via the oral approach and showed a blood clot on the suspected submucosal tumor of jejunum. A hemostatic clip was placed at the base of the lesion to allow the surgeon to locate it during the operation. Laparoscopy was performed, and the lesion was resected.Outcomes:The postoperative pathology showed a Dieulafoy lesion. The lower extremity edema subsided. GI bleeding did not recur over 1 year of follow-up, and hemoglobin was 12.2 g/dL. A Dieulafoy lesion is a rare cause of GI bleeding, and it is even rarer in the jejunum.Lessons:A Dieulafoy lesion does not have special imaging features, but the presence of calcifications in the small intestine on computerized tomography might be suspicious of the diagnosis. When endoscopic treatment is difficult, surgical treatment could be considered.