Colonic obstruction due to rectal endometriosis: report of a case.

Although endometriosis is a common disease in women of childbearing age, intestinal endometriosis is unusual and may cause clinically significant complications. We report a 46-year-old woman with rectal endometriosis who presented with intestinal obstruction. She was operated on with a preoperative diagnosis of malignancy. The diagnosis of endometriosis was made only after histological examination of the resected specimen. Intestinal endometriosis has a diverse clinical spectrum, with nonspecific features in many patients. In female patients who have unexplained digestive complaints, endometriosis should also be considered in the differential diagnosis.     

Crohn＇s disease complicated by multiple stenoses and interna fistulas clinically mimicking small bowel endometriosis

We report a 31-year-old woman with Crohn＇s disease complicated by multiple stenoses and internal fistulas clinically misdiagnosed as small bowell endometriosis, due to the patient＇s perimenstrual symptoms of mechanical subileus for 3 years; at first monthly, but later continuous, and gradually increasing in severity. We performed an exploratory laparotomy for small bowel obstruction, and found multiple ileal strictures and internal enteric fistulas. Because intraoperative findings were thought to indicate Crohn＇s disease, a right hemicolectomy and partial distal ileum resection were performed for obstructive Crohn＇s ileitis. Histopathology of the resected specimen revealed Crohn＇s disease without endometrial tissue. The patient made an uneventful recovery from this procedure and was discharged home 10 d post-operatively. The differential diagnosis of Crohn＇s diease with intestinal endometriosis may be difficult pre-operatively. The two entities share many overlapping clinical, radiological and pathological features. Nevertheless, when it is difficult to identify the cause of intestinal obstruction in a woman of child- bearing age with cyclical symptoms suggestive of small bowel endometriosis, Crohn＇s disease should be included in the differential diagnosis.     

Anasarca and small bowel obstruction secondary to endometriosis

Intestinal involvement by endometriotic tissue occurs in up to 37% of patients with endometriosis. The vast majority of patients do not experience symptoms related to the gastrointestinal tract. In particular, the complications of intestinal obstruction and malabsorption secondary to endometriosis are exceedingly uncommon. We present a 42-year-old woman with intestinal obstruction, protein-losing enteropathy, and anasarca secondary to endometriosis. She had a 1-year history of watery diarrhea, bloating, and abdominal pain with a 30-lb weight-loss over 3 months. She had no previous history of endometriosis, and laboratory investigations showed severe hypoalbuminemia, hypokalemia, and metabolic acidosis. Abdominal x-rays revealed air-fluid levels and dilated loops of small bowel. She underwent surgical resection with primary anastomosis. Pathologic evaluation showed extensive endometriosis of the small bowel and appendix, which resulted in complete obstruction. Segments of ileum also demonstrated moderate-to-marked blunting of the villi. Postoperatively, the patient had a slow recovery with resolution of anasarca and a gradual increase in her weight. This report illuminates the rare, yet significant, complications of intestinal endometriosis, including small bowel obstruction, the development of a protein-losing enteropathy, and anasarca. One should consider the possibility of intestinal endometriosis in the differential diagnosis of bowel obstruction in women of childbearing age.     

Exclusive ileal endometriosis

Endometriosis is a common condition, but its exclusive localization on the ileum is very rare. Unless there is catamenial exacerbation of symptoms, and considering the lack of specificity of results, diagnosis can be difficult. We report the case of a 50 year-old woman presenting with chronic pain in the right lower quadrant. Initial explorations revealed an ileal tumor which was not characterized before the occurrence of acute small bowel obstruction. Ileo-caecal resection by laparotomy relieved the symptoms and alllesions were removed. Diagnosis of ileal endometriosis was made by pathological examination of the resected specimen.     

Acute small bowel obstruction caused by endometriosis：A case report and review of the literature

Gastrointestinal involvement of endometriosis has been found in 3%-37% of menstruating women and exclusive localization on the ileum is very rare（1%-7%）.Endometriosis of the distal ileum is an infrequent cause of intestinal obstruction,ranging from 7% to 23% of all cases with intestinal involvement.We report a case in which endometrial infiltration of the small bowel caused acute obstruction requiring emergency surgery,in a woman whose symptoms were not related to menses.Histology of the resected specimen showed that endometriosis was mainly prevalent in the muscularis propria and submucosa and that the mucosa was not ulcerated but had inflammation and glandular alteration.Endometrial lymph node involvement,with a cystic glandular pattern was also detected.     

A patient with rectal ulcer with severe stenosis presenting with perforated peritonitis

We report a patient with rectal ulcer with severe stenosis, who underwent urgent surgical treatment for perforated peritonitis. The 54-year-old man suddenly developed cramping abdominal pain and fever while hospitalized, with signs of peritoneal irritation. An emergency laparotomy was performed, and severe stenosis of the rectum and a perforated lesion on the oral side approximately 10 cm distant from the stenosis were found, with massive abdominal purulent fluid. He was treated by rectosigmoid colon resection with transverse colon loop colostomy. Histopathologically, the stenosis was caused by ulceration extending to all muscular layers of the rectum, with inflammatory changes. Benign rectal stenosis is so rare that differential diagnosis from malignancy may be difficult when there are inflammatory changes in the surrounding tissues. However, it is necessary to keep in mind the likelihood of this disease in differentiation from rectal cancer. Received: December 21, 1998 / Accepted: May 28, 1999     

Wind Sock Deformity in Rectal Atresia

Rectal atresia is a rare anorectal deformity. It usually presents with neonatal obstruction and it is often a complete membrane or severe stenosis. Windsock deformity has not been reported in rectal atresia especially, having been missed for 2 years. A 2-year-old girl reported only a severe constipation despite having a 1.5-cm anal canal in rectal examination with scanty discharge. She underwent loop colostomy and loopogram, which showed a wind sock deformity of rectum with mega colon. The patient underwent abdominoperineal pull-through with good result and follow-up. This is the first case of the wind sock deformity in rectal atresia being reported after 2 years of age.     

Pelvic endometriosis simulating colonic malignant neoplasm

Three women had endometriosis that involved the rectosigmoid colon; their clinical presentation suggested primary colonic malignant neoplasm. Intestinal obstruction, weight loss, and, in two patients, rectal bleeding with radiologic evidence of a mass lesion that involved the rectosigmoid were present at initial evaluation. All patients eventually underwent colonic resection as definitive therapy. Endometriosis of the pelvic colon may mimic primary intestinal disease, mistakenly suggesting malignant neoplasm. Such symptoms in a young woman should prompt a search for endometriosis, which is a more likely diagnosis. Adequate therapy frequently requires surgical intervention.     

Colonic endometriosis

Conclusion Endometriosis of the sigmoid flexure and rectosigmoidal area should be suspected in any woman who has symptoms of progressive colonic obstruction, pain on defecation, abdominal cramps and rectal bleeding associated with menstruation. Sigmoidoscopy should be performed in all these patients, but usually it will reveal no lesion. The only suggestive finding which might be found on sigmoidoscopy is a submucosal lesion covered by a puckered but intact mucosa. X-rays of the colon after barium enema may show a polypoid lesion but, more commonly, it will show a constricted area. Usually differentiation from carcinoma of the rectosigmoid is not possible by x-ray examination, but an intact mucosa in the narrowed area would favor a diagnosis of colonic endometriosis. Treatment should be determined according to the individual and should depend on the age of the patient and the severity of symptoms. Patients with minimal obstructive symptoms and moderate colonic involvement revealed by x-ray examination usually do not require a surgical operation. A patient in this category who is less than 40 years of age may show a remarkable response to suppressive hormonal therapy. Patients more than 40 years old may show dramatic relief of symptoms and regression of the colonic deformity after hysterectomy and oophorectomy. Surgical removal of the involved portion of the colon is indicated (1) in patients who have progressive or acute colonic obstruction associated with increasing pelvic discomfort, rectal bleeding and constipation associated with the menstrual cycle (2) to determine if the lesion is an adenocarcinoma of the rectosigmoid, and (3) when the x-ray examination shows a persistent constricted area in the rectosigmoid.     

Inflammatory fibroid polyp of rectum mimicking rectal cancer

Inflammatory fibroid polyps (IFPs) are rare benign tumors of the rectum. Mutation and activating platelet-derived growth factor receptor alpha (PDGFRA) contribute to tumor development. We present a case of IFPs in the middle rectum that mimic rectal cancer. A 65-year-old woman presented with the symptom of fresh blood in the stool and body weight loss of 6 kg in the preceding 3 weeks. A rectal polypoid tumor was noted upon digital examination. Sigmoidoscopy showed a middle rectal tumor measuring 3 × 2.7 cm with obstruction. Computed tomography (CT) scans of the abdomen showed a rectal tumor that had invaded the sacral bone and was associated with four enlarged lymph nodes greater than 1 cm. The radiological report suggested a diagnosis of rectal cancer with lymph node metastases. To remove the obstruction, the patient was initially treated with excision of the tumor and loop sigmoidal colostomy to the abdomen wall. Total mesorectal resection of rectal and sacral tumor followed 10 days later. Histopathological examination of the rectal and sacral tumor showed proliferation of vessels, fibroblast-like spindle cells, and mixed inflammatory cells, including the plasma cells and eosinophils. The spindle cells were diffusely positive to PDGFRA and were focal positive to CD34 and smooth muscle actin. Based on histopathological and immunohistochemical findings, the diagnosis of IFP is indicated. This was the first reported case of IFPs of the rectum presenting with lymph node enlargement and attachment to the sacrum mimicking rectal cancer.     

Endoscopic laser palliation for rectal cancer-- therapeutic outcome and complications in eighty-three consecutive patients

OBJECTIVE: The treatment of advanced rectal cancer is still a challenge. We analysed the short-term success, treatment-related complications and the long-term outcome after laser palliation for rectal cancer. METHODS: Over a ten-years period eighty-three consecutive patients (median age 81 (46-94) yrs; 43 female) were treated mainly for obstructive symptoms or tumour bleeding. Laser palliation was performed using a Neodymium:Yttrium-Aluminium-Garnet (Nd:YAG) laser. RESULTS: The immediate overall-success rate was 96.4 % (80 of 83 patients) and only one female received a diverting colostomy because of an inaccessible high-grade rectal stenosis, initially. During follow-up, eight additional patients had to undergo surgery on their rectal cancer because of treatment failures (most of them recurrent obstruction) or complications (long-term success rate: 86.7 % (72 of 83 pts.)). The median survival period was nine months. Patients treated for obstruction had more treatment sessions and had a higher rate of surgical palliation in comparison to those pts. therapied for bleeding. Major complications were seen in three patients (3.6 %). One patient died after rectal perforation following bougienage before laser treatment (overall mortality: 1.2 %). CONCLUSION: Laser therapy is effective for the palliation of advanced rectal cancer with a high short-term and long-term success rate and only few complications. Laser treatment therefore is still a valuable alternative to newer endoscopic techniques and surgery.     

Recurrent sanguineous and mucous diarrhea and spasms in a 46-year-old woman--manifestation of endometriosis in the colon sigmoideum

Intestinal endometriosis is the most frequent extragenital manifestation of this disease. Sometimes patients even present with acute bowel obstruction. We report on a 46-year-old woman complaining about recurrent sanguineous and mucous diarrhea and spasms for several years. Colonoscopy showed a stenosis in the sigmoid colon without macroscopically visible alterations of the mucosa. Computertomography, ultrasound and barium contrast enema did not provide us with further information about the origin of the stenosis. Biopsies out of the mucosa at the stenosis showed typical endometriosis tissue. After starting a conservative therapy with GnRH-agonist gosereline the patient became completely free of symptoms. The coincidence of endometriosis and M. Crohn has to be taken into consideration. Therapy planning should include a close co-operation with gynaecologists and surgeons to transfer the patient to surgical intervention when needed.     

Right-ventricular hemangioma causing serious outflow-tract obstruction

A 28-year-old woman had a partially nonexertional dyspnea and a murmur of pulmonary stenosis. Echocardiography and magnetic resonance imaging revealed a mass causing a nearly completely pulmonary outflow-tract obstruction. The mass was successfully resected and the pathological diagnosis of a mixed capillary and cavernous polypoid hemangioma was made. This case represents one of the very rare cases of a right-ventricular hemangioma in adults in which obstruction of the outflow-tract was initially evident. Non-invasive diagnosis and an exploratory operation with resection is the procedure of choice.     

Communicating multiple tubular enteric duplication with toxic megacolon in an infant: A case report

Rationale:Gastrointestinal tract duplication is a rare congenial anomaly which can be found anywhere along the gastrointestinal tract. While many patients are incidentally diagnosed during operation, in some cases it can present with severe gastrointestinal symptoms. In this case report, the patient presented with signs of toxic megacolon leading to rapid aggravation of inflammatory shock.Patient concerns:A 49-day old male infant presented with fever, poor feeding, and severe abdominal distension.Diagnosis:Abdominal ultrasonography was done. During the examination, a foley catheter was inserted through the anus to evaluate bowel patency and enable rectal decompression. The tip of the foley catheter was located in a separate narrower tubular lumen adjacent to the distended rectum. These findings suggested possibility of a tubular duplication cyst of the rectum as the culprit for the bowel obstruction.Interventions:The patient underwent emergency laparotomy. Findings showed multiple tubular intestinal duplications involving the ileum, appendix, cecum, descending colon, sigmoid colon and rectum. The true lumen of the rectosigmoid colon was completely collapsed while the adjacent tubular cyst remained severely distended and stool passage was not possible. Decompression of the sigmoid colon was done with loop colostomy with both the wall of the true bowel and enteric cyst forming the colostomy orifice.Outcomes:After 40 days of postoperative care, the patient was discharged with no immediate complications. Four months after the initial operation, colostomy take-down and transanal rectal common wall division was done. No complications were observed.Lessons:To our knowledge, this is the first case to be reported where a rare presentation of intestinal duplication resulted in an acute presentation toxic megacolon. Such emergency cases can be effectively treated with emergency surgical bowel decompression and elective common wall division.     

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.     

Adult idiopathic subglottic stenosis: a diagnostic and therapeutic challenge

A 22-year-old woman presented with effort dyspnea unresponsive to bronchodilators. Harsh respiratory sounds were audible at the neck. Thoracic and cardiac evaluation was normal. Spirometry revealed an obstructive ventilatory defect, and the flow-volume loop indicated upper airway obstruction. Bronchoscopy and tracheal computed tomography revealed a stenosis of the subglottic larynx. A biopsy specimen of the stenotic area of the trachea showed a normal mucosa and non-specific chronic inflammation. The tracheal stenosis was managed by means of endobronchial laser therapy, which led to the resolution of the patient's symptoms. As we could not identify any specific pathogenetic process, our final diagnosis was idiopathic subglottic tracheal stenosis.     

Duodenal stenosis in coincidence with annular pancreas and cancer of the papilla

We report on a case of annular pancreas complicated by the development of a carcinoma of the papilla causing secondary chronic obstructive pancreatitis. Eventually, a high-grade stenosis of the duodenum developed, leading to symptoms of gastric outlet obstruction. The stenosis was proved by endoscopic and radiologic diagnosis, but the exact anatomical condition was only revealed by an operation. Efficient diagnostic and therapeutic procedures in annular pancreas with its potential complications are discussed in detail.     

Solitary rectal ulcer induced by excessive use of analgesic suppositories containing paracetamol, caffeine, and codeine

We report the case of a 53-yr-old woman who developed an ulcer of the distal rectum with mild stenosis after prolonged use of suppositories containing paracetamol, caffeine, and codeine. After undergoing extensive diagnostic tests with exclusion of other possible causes, she admitted to the abuse of the suppositories. She was treated with frequent endoscopic balloon dilations to prevent progression of the rectal stenosis. Because of severe pain on defecation, she needed a protective colostomy which could be closed after the healing of the ulcer 7 months later. There was no significant residual stenosis. This case is compared to cases described in the past 30 years.     

Appendiceal Endometriosis Presenting as Massive Lower Intestinal Hemorrhage

Appendiceal endometriosis is a very uncommon clinical entity. We describe a 33-yr-old white female who presented with painless profuse rectal bleeding. Emergency colonoscopy revealed bleeding from the appendiceal opening. An emergency appendectomy was performed which controlled her bleeding. The histopathological examination demonstrated appendicesl endometriosis. Painless bleeding from appendiceal endometriosis is extremely rare; however, it should be considered when evaluating young women of reproductive age who present with rectal bleeding.     

Role of EUS and EUS-guided FNA in the diagnosis of symptomatic rectosigmoid endometriosis

BACKGROUND: Rectosigmoid endometriosis is an underrecognized cause of GI symptoms in women. Pelvic magnetic resonance imaging and CT have a low sensitivity in making this diagnosis. The role of EUS and EUS-guided FNA (EUS-FNA) in the diagnosis of rectosigmoid endometriosis in symptomatic patients is not well studied. METHODS: A review of medical records identified 5 women who were diagnosed with rectosigmoid endometriosis by EUS and EUS-FNA over a period of 1 year. OBSERVATIONS: Five women with nonspecific GI complaints underwent EUS examination of a rectosigmoid subepithelial mass found on colonoscopy. EUS revealed a hypoechoic lesion infiltrating the muscularis propria and the serosa of the rectal wall, and extending outside the rectal wall, findings consistent with rectosigmoid endometriosis. This diagnosis was confirmed by EUS-FNA, surgical exploration, and/or the patient's clinical course. CONCLUSIONS: EUS and EUS-FNA are noninvasive, sensitive techniques for the diagnosis of rectosigmoid endometriosis in symptomatic patients.