Rectal endometriosis: high sensitivity and specificity of endorectal ultrasound with an impact for the operative management

Purpose In patients with histopathologically proven or suspected endometriosis with possible involvement of the rectum, endorectal ultrasound was performed to determine the sensitivity and specificity of this method with regard to rectal wall involvement and the impact on the following operation. METHODS: In an historical cohort analysis, 85 females with histopathologically proven or suspected endometriosis with possible involvement of the rectum were treated between 1992 and 2001. Endorectal ultrasound was performed with a 7.5 MHz real-time unit, and results of endorectal ultrasound were compared with intraoperative findings and histopathologic diagnosis of 65 patients undergoing operation. A questionnaire was used to evaluate postoperative signs and symptoms. RESULTS: Of 65 patients undergoing surgery, 37 underwent laparotomy with 25 resections of the bowel and 28 laparoscopy. In 31 of 32 patients with suspected rectal wall infiltration, preoperative endorectal ultrasound diagnosis was confirmed. In patients in whom endorectal ultrasound showed no rectal wall involvement, histopathology revealed infiltration in one patient, leading to sensitivity of 97 percent and specificity of 97 percent with regard to rectal wall involvement. In terms of the deepness of rectal wall infiltration, endorectal ultrasound had a sensitivity of 76 percent with regard to infiltration of the muscularis propria and 66 percent for infiltration of the submucosa. Operations led to a significant (P< 0.05) reduction of preoperative symptoms by approximately 60 percent. CONCLUSIONS: Endorectal ultrasound is a useful, noninvasive technique for preoperative evaluation of possible rectal wall involvement in endometriosis. Based on the high sensitivity and specificity, recommendation for laparotomy and bowel resection in cases with suspected rectal involvement can be facilitated. Supported by the Department for General and Thoracic Surgery. University of Kiel.     

Primary malignant melanoma of the rectum

We present a case of primary malignant melanoma arising in the rectum of a 71-year-old woman who had presented with intermittent rectal bleeding following bowel movement 2 months previously. Digital and sigmoidoscopic examination of the rectum revealed a 3 ×2×1 cm exophytic tumor with a granular surface in the rectum 35 mm from the dentate line. No increased pigmentation was detected. Biopsy revealed degenerated mucosa accompanied by severe infiltration of inflammatory cells, but no malignant cells. The tumor and normal mucosa surrounding the tumor was excised 12 days after the biopsy. Light microscopy revealed the tumor to consist of malignant melanocytes and showed that the tumor was surrounded by normal mucosa. Immunohistochemical staining with antimelanoma antibody and HMB-45 substuntiated the diagnosis. Clinical and laboratory examination excluded the presence of melanoma at sites other than rectum. The patient refused an abdomino-perineal resection of the rectum and combination chemotherapy was performed. She died 18 months after the initial operation due to local recurences and metastases to pelvic lymph nodes, liver, and lung.     

Rectal endometriosis: a case report

We present the case of a 45-year-old female patient who was admitted with a history of pelvic pain, constipation, and dysmenorrhea. CT scan and u/s images revealed cholelithiasis, benign nodular hyperplasia of segment IV of the liver and uterine fibromyoma. During laparotomy, firm adhesions between the posterior wall of the uterus and the rectum were found and the incisional biopsy reveals an undifferentiated adenocarcinoma. Then, total resection of the uterus was performed with en block resection of the adherent part of the rectum and part of the posterior wall of the vagina. The final histopathological report showed the presence of uterine fibromyoma, nodular hyperplasia of the liver and rectal endometriosis without any sign of malignancy. The patient after 5 years of follow up remains healthy. Rectal endometriosis represents an uncommon localization of pelvic endometriosis where the symptoms and clinical findings are non-specific making the definitive preoperative diagnosis difficult. Endometriosis should be included in the differential diagnosis of chronic pelvic pain in combination with defecation disorders in female patients of reproductive age.     

Sigmoid colon endometriosis treated with laparoscopy-assisted sigmoidectomy： Significance of preoperative diagnosis

We present a female patient with sigmoid colon endometriosis who was diagnosed correctly preoperatively and underwent minimally invasive surgery. She was admitted to our hospital with rectal bleeding and constipation. We performed several workups. Colonoscopy and endoscopic ultrasonography showed sigmoid colon stenosis caused by submucosal tumor, and magnetic resonance imaging revealed a sigmoid colon tumor displaying signal hy- pointensity on both T1- and T2-weighted imaging. However, colonoscopic ultrasonography-assisted needle aspiration biopsy could not specify tumor characteristics. From these examinations, the lesion was diagnosed as sigmoid colon endometriosis and laparoscopy-assisted sigmoidectomy was performed. Pathological diagnosis from the resected specimen was identical to preoperative diagnosis, i.e., colonic endometriosis. Since differential diagnosis of intestinal endometriosis seems difficult, a cautious preoperative diagnosis is required to select treatments including minimally invasive surgery.     

Granular cell tumor of the rectum: a case report and review of the literature

A 47-year-old Japanese woman with a 5-year history of alcoholism was admitted to the Ryukyu University Hospital for the treatment of the alcoholism. For evaluation of observed changes in her bowel habits, she underwent colonoscopy, which revealed seven small polyps spread throughout the entire large intestine. Six of the polyps were in the colon; one was an adenoma and five were hyperplastic polyps. The remaining polyp, in the rectum, was an 8-mm submucosal tumor. Pathological analysis of a biopsy of the lesion in the rectum indicated a possible diagnosis of adenocarcinoma. Endoscopic ultrasonography (EUS) demonstrated a submucosal hypoechoic nodule, involving the mucosa and the muscularis propria. Subsequently, the patient underwent a radical low anterior resection of rectum. The lesion was a submucosal tumor with ulceration. The tumor consisted of granular tumor cells which were positive for S-100 protein, neuron-specific enolase, and periodic acid schiff (PAS) stain, but negative for desmin and vimentin. Granular cell tumor is rare in the gastrointestinal tract. As a result, such tumors can be misinterpreted to indicate a possible malignancy on either a biopsy or EUS. Received: July 9, 1999 / Accepted: December 17, 1999     

A case of primary rectal mucosa‐associated lymphoid tissue lymphoma treated by endoscopic mucosal resection

A 53‐year‐old man underwent surveillance colonoscopy that revealed a submucosal tumor‐like polypoid lesion on the Rb area of the rectum. Histological examination of biopsy specimens showed chronic inflammation. Endoscopic mucosal resection was performed after obtained informed consent for the purpose of obtaining accurate diagnosis and for curative treatment. Pathological findings of the resected specimen showed low‐grade B‐cell lymphoma of mucosa‐associated lymphoid tissue type (MALT lymphoma). Gallium‐scintigraphy, abdominal CT, small bowel series and endoscopic examination of the upper gastrointestinal tract revealed no abnormalities. Based on the findings, a diagnosis of stage IE lymphoma was made. However it was suspected that the vertical cut‐end of the resected specimen had residue of lymphoma cells. Additional transanal resection of the rectum was therefore performed, but no lymphoma cells were found in the specimen. Eradication of Helicobacter pylori was also performed. Although a standard therapeutic strategy for colonic MALT lymphoma has not been established, endoscopic mucosal resection might be a good therapeutic choice.     

Rectal submucosal tumor-like lesion originating from intestinal tuberculosis

We present the case of a 55-year-old man who underwent transsacral local excision for a rectal submucosal tumor-like lesion suspected to originate from tuberculosis. The lesion, 2 cm in size, was found incidentally in the posterior wall of the lower rectum during anal fistulectomy. The lesion was apart from the primary crypt of the anal fistula. Barium enema and colonoscopy revealed a protuberant submucosal growth with a shallow depression of the overlying mucosa. Although computed tomography and magnetic resonance imaging showed a well defined round mass within the rectal wall, digital rectal examination suggested extramural origin. Since repeated endoscopic biopsies were negative, we selected the transsacral approach for excisional biopsy to achieve histological diagnosis. The lesion was confined to the rectal wall and the full-thickness rectal wall was excised. Histologically, a foreign-body granuloma with acute inflammation was the main component of the lesion. Caseating granulomas and Langhans' giant cells, consistent with tuberculosis, were also found.     

Tracheo-bronchitis associated with Crohn's disease improved on inhaled corticotherapy

We report a case of tracheo-bronchitis in Crohn's disease. A 23-year-old Japanese woman who had been diagnosed with Crohn's disease three years previously was hospitalized. She had been suffering from dry cough for one month. Computed tomography of the chest revealed marked thickening of the tracheal wall. Bronchoscopy showed erythematous and edematous mucosa with diffuse whitish granular lesions in the trachea and bronchi. The bronchial biopsy specimens showed non-specific inflammatory infiltrates consisting of lymphocytes and plasma cells, and hyperplasia of bronchial glands. Inhaled corticotherapy, fluticasone propionate 800 microg/day, was effective for both the inflammatory mucosa and thickened tracheal wall.     

Inverted Meckel's diverticulum preoperatively diagnosed using double-balloon enteroscopy

An inverted Meckel's diverticulum is a rare gastrointestinal congenital anomaly that is difficult to diagnose prior to surgery and presents with anemia, abdominal pain, or intussusception. Here, we report the case of 57-year-old men with an inverted Meckel's diverticulum, who was preoperatively diagnosed using doubleballoon enteroscopy. He had repeatedly experienced epigastric pain for 2 mo. Ultrasonography and computed tomography showed intestinal wall thickening in the pelvis. Double-balloon enteroscopy via the anal route was performed for further examination, which demonstrated an approximately 8-cm, sausage-shaped, submucosal tumor located approximately 80 cm proximal to the ileocecal valve. A small depressed erosion was observed at the tip of this lesion. Forceps biopsy revealed heterotopic gastric mucosa. Thus, the patient was diagnosed with an inverted Meckel's diverticulum, and single-incision laparoscopic surgery was performed. This case suggests that an inverted Meckel's diverticulum should be considered as a differential diagnosis for a submucosal tumor in the ileum. Balloon-assisted enteroscopy with forceps biopsy facilitate a precise diagnosis of this condition.     

Endoscopic ultrasonographic findings in rectal leiomyoma

Abstract A 35 year old man visiting a hospital for his annual check-up in August 1992 was found to have a large rectal tumour on digital examination. Colonoscopy revealed a bulging lesion with normal mucosa. Endoscopic biopsy showed only normal tissue. Endoscopic ultrasonography demonstrated a large hypo-echoic submucosal tumour in the fourth layer (muscularis propria) of the rectal wall. Based on this endoscopic ultrasonographic finding, we diagnosed the tumour as leiomyoma pre-operatively. The tumour was excised by a trans-sacral local excision. The histological diagnosis of the resected specimen was cellular leiomyoma.     

Pituitary tuberculoma: an unusual lesion of sellar region

Pituitary tuberculomas are extremely rare lesions, with only few cases described in the literature, usually mistaken as pituitary tumors. Its heterogeneous clinical and imaging profile preclude preoperative diagnosis which ultimately relies on the histopathological examination. We describe a 46 years old woman who presented with an episode of confusion and hypopituitarism with no evidence of systemic tuberculosis. Computed tomography (CT) showed a central calcified and enhancing sellar mass. Magnetic resonance imaging (MRI) showed a sellar mass with suprasellar extension and associated optic chiasm compression. She was submitted a craniotomy for biopsy and resection. A caseous material was found at the center of the lesion involved by a thick wall. Due to the wall adherence to the optic chiasm and the inflammatory aspects of the lesion, subtotal removal was achieved and the patient followed on anti-tuberculous and hormonal replacement therapy. Sellar tuberculomas should be considered in the differential diagnosis of sellar tumors in order to offer appropriate treatment.     

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.     

Primary lymphoma of the vagina

Primary vaginal non-Hodgkin's lymphomas (NHL) are rare, and are clinically difficult to differentiate from inflammatory diseases or vaginal cancer. Here, we present such a case in a 74-year-old woman complaining of fever and difficulty with urination. Pelvic examination revealed a tumor involving most of the vaginal wall, and pelvic MRI demonstrated vaginal wall thickening. A biopsy of this lesion confirmed NHL (diffuse large B-cell lymphoma), and the patient was admitted. Abdominal CT and MRI detected a vaginal tumor, and Ga scintigraphy confirmed accumulation in the pelvis, but no abnormalities were seen in other areas. Therefore, the patient was diagnosed as having NHL at clinical stage IB with low-intermediate risk (international prognosis index) (LDH 1,309 IU/L). The patient underwent three courses of CHOP therapy followed by radiotherapy, and complete remission was achieved. Primary vaginal NHL often affects women younger than 50 years of age, and abnormal hemorrhage is the initial symptom in many cases. There have been a number of reports of long-term survival following appropriate early chemotherapy and radiation therapy, suggesting that early diagnosis and treatment based on vaginal biopsy findings greatly influence the prognosis.     

A case of cancerous familial adenomatous polyposis in urinary bladder due to migration of colonic mucosa through rectovesical fistula

The patient was a 50-yr-old man who had undergone low anterior resection for rectal cancer at the age of 24 yr in 1966. At that time, gastric and colonic polyposis were indicated. Postoperative anastomotic dehiscence occurred and, by 1985, a rectovesical fistula had formed. In 1986, when the patient was 44 yr old, he was examined at our hospital for constriction of the rectum due to the rectovesical fistula. Abdominoperineal excision of rectum and surgical closure of the fistula were performed, and the patient was kept under observation because of a diagnosis of familial adenomatous polyposis. In 1988, when the patient was 46 yr old, early ascending colon cancer was discovered and total colectomy was performed. Then, in December, 1991, gross hematuria was found. Further examination revealed a tumor on the posterior wall of the urinary bladder lumen, and biopsy showed adenocarcinoma. Pelvic recurrence of the rectal cancer was diagnosed, and total pelvic exenteration was performed. There were no distant metastases; histologically, the tumor of the bladder was thought to be due to colonic mucosa of familial adenomatous polyposis that had migrated to the bladder lumen via the rectovesical fistula and had become cancerous.     

A Case of Rectal Carcinoma in a Part of a Giant Periproctal Abscess

Abstract: A 58-year-old male was admitted to our hospital complaining of perineal pain and weight loss. On digital examination, a hard mass with a central depression was palpable in the circumference of the rectum. A barium enema study revealed a giant periproctal abscess formation, and a colonoscopy showed a giant irregular-shaped ulceration in the circumference of the rectum. Biopsy specimens obtained from the rectal ulcer revealed a well differentiated adenocarcinoma, and this case was diagnosed as being carcinoma of the rectum with periproctal abscess formation. A pelvic exenteration and colostomy were performed. The macroscopic findings of the resected rectal specimen showed a giant abscess formation measuring 13 cm over the anal verge in the circumference of the lower rectum. The abscess, with a thickened wall measuring 50 mm, was accompanied by an ulcerated lesion on its oral and anal side. The tumor was adherent to the bladder and prostate with direct invasion. The post operative diagnosis made was an unclassified type of rectal carcinoma (type 5). Its clinical staging was stage 5 (HIPON1A3) in gross appearance. The histopathological findings of the resected specimen indicated a poorly differentiated adenocarcinoma partly containing signet ring cell carcinoma. The frequency with which a rectal carcinoma with a regional abscess has been reported is less than 1%. It has been assumed that a regional abscess is caused by the perforation of the rectum contributing with the invasion of carcinoma over the proper muscle layer. In this case, it was inferred that the rapid development of this tumor caused secondary, ischemia at its center and then an abscess was formed with tumor necrosis.     

Rectal obstruction due to endometriosis

Although endometriosis is a disorder commonly found in reproductive-age women, it does not involve the bowel very often. The circumferential involvement of the rectum is rare and the obstructive symptoms can be difficult to differentiate from those of inflammatory or malignant diseases. We report two patients with rectal endometriosis whose first prominent symptoms were those of intestinal obstruction. A 26-year-old woman was admitted with obstructive symptoms. In order to alleviate the obstruction and extend the preoperative evaluation, a decompressive colostomy was done. The diagnosis of endometriosis was made by laparoscopy and biopsies of the thickened cul-de-sac peritoneum. Another woman, 40 years of age, was referred to us with a colostomy. She had undergone a laparotomy due to an obstructive acute abdomen a year before, and a frozen pelvis was found. Biopsy specimens had been collected and the pathological report revealed endometrioma. A rectosigmoidectomy, encompassing the stenotic rectal segment, was done along with primary anastomosis. The pathological examination confirmed rectal endometriosis. The conclusion is that, although rare, rectal endometriosis can cause significant stenosis of the organ, leading to obstructive symptoms. Despite its low frequency, it should always be considered in the differential diagnosis of rectal stenosis involving women of childbearing age.     

A case of a duodenal gastrointestinal stromal tumor diagnosed with the aid of diffusion-weighted magnetic resonance imaging

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumor of gastrointestinal tract, and bleeding is among the primary symptoms. If the tumor is located in the small intestine, diagnosis might be difficult because of its inaccessibility by endoscope. This report presents a case of duodenal GIST diagnosed with the aid of diffusion-weighted (DW) magnetic resonance imaging (MRI). A 66-year-old male was admitted to the hospital because of shortness of breath and melena. The patient demonstrated marked anemia. Esophagogastroduodenoscopy and colonoscopy revealed no involvement of the mucosa of the gastrointestinal tract in regard to the observed bleeding. Thereafter, computed tomography was done and showed a tumorous lesion 4.2 cm in diameter located around the ligament of Treitz. The area showed significant high intensity by DW-MRI, strongly suggesting malignant character. Examination with a long endoscope demonstrated a large submucosal tumor with wide ulceration located at the third portion of the duodenum. The biopsy sample contained spindle-shaped cells that were positive for CD34 and c-kit on histochemistry, and the tumor was diagnosed as GIST. The patient underwent surgery and survived for 16 months without any recurrence.     

A case of collagenous gastritis resembling nodular gastritis in endoscopic appearance

A 25-year-old Japanese female was referred to our clinic for the investigation of moderate iron-deficiency anemia and epigastralgia. Endoscopic examination showed diffuse mucosal nodules in the gastric body resembling nodular gastritis, but this pattern was not observed in the antrum. Histology of the gastric biopsies taken from the gastric body showed mild atrophic mucosa with chronic active inflammation. Some of the biopsy specimens showed deposition of patchy, band-like subepithelial collagen. Four years later, the patient showed no clinical symptoms and signs. A follow-up endoscopic examination showed similar findings, which mimicked pseudopolyposis or a cobblestone-like appearance. The biopsy specimens from the depressed mucosa between the nodules revealed a thickened subepithelial collagen band with no improvement, which led to a diagnosis of collagenous gastritis. Treatment with oral administration of proton-pump inhibitors and histamine-2-receptor antagonists had proved ineffective. To make a correct diagnosis of collagenous gastritis, we should determine the characteristic endoscopic findings and take biopsies from the depressed mucosa between the nodules.     

Endoluminal ultrasound diagnosis and operative management of rectal endometriosis

PURPOSE: Endorectal ultrasound was performed in patients with endometriosis to evaluate the role of this technique for rectal wall involvement and to evaluate the position of preoperative diagnosis in the operative management of rectal endometriosis. METHODS: Sixteen patients with suspected fixation of endometriomas to the rectal wall during bimanual examination were included in the study. Endorectal ultrasound was performed using a real time unit with a 7.5 MHz endorectal transducer. The probe was introduced via a rectoscope into the rectum up to the rectosigmoid. RESULTS: Endometriosis was confirmed histopathologically in all patients. In six patients rectal wall involvement was diagnosed, in two patients endometriomas were adjacent to the rectal wall, and in eight patients rectal wall involvement could be excluded. Preoperative diagnosis was confirmed in all patients during operation. Laparotomy was performed in those patients with preoperatively diagnosed rectal wall involvement, whereas the remaining patients were treated laparoscopically. Endometriomas with rectal wall involvement were treated in five of six patients with resection of the affected bowel predominantly by low anterior resection. CONCLUSIONS: Preoperative endorectal ultrasound is a reliable technique to visualize perirectal endometriomas and to assess rectal wall involvement. Based on preoperative endosonographic diagnosis, an operative management was established with laparotomy and resection of the affected bowel in cases of rectal wall involvement.     

Gastritis cystica profunda in a previously unoperated stomach:A case report

Gastritis cystica profunda is a relatively rare disease, usually observed at anastomotic sites in stomachs of patients that have undergone gastric procedures. We present the rare case of an elevated lesion in the anterior wall of the gastric antrum of a 43-year-old Chinese woman who had never undergone gastric surgery and had no gastrointestinal tract symptoms. Although the physical examination and laboratory data showed no abnormalities, endoscopic ultrasonography revealed an anechoic cystic structure. Abdominalcomputed tomography and magnetic resonance imaging showed the gastric wall of the greater curvature of the antrum was markedly and irregularly thickened, and mild to moderate enhancement was observed around the lesion with no enhancement in the central portion, suggestive of a gastrointestinal stromal tumor. The patient underwent a distal gastric resection of the 2.5 cm × 1.5 cm lesion. A postoperative pathologic examination showed dilated cystic glands in the muscularis mucosa and submucosal layers and erosion of the mucosal surface of the tumor, confirming the diagnosis of gastritis cystica profunda without malignancy.