Endometriosis with an acute colon obstruction: a case report

Abstract

Introduction: The presentation of an acute bowel obstruction caused by endometriosis in an emergency department setting is rare, as it usually presents through years of complaints in the absence of a distinct acute onset. In this report, we present a case of a patient who was familiar with abdominal complaints and eventually required emergency surgery to treat an acute bowel obstruction caused by endometriosis. Endometrioses present infrequently in the acute phase, and only a few cases in which emergency surgery was required have been described in the literature.

Case presentation: A 31-year-old Caucasian woman presented to the emergency room of our hospital with a distended abdomen, pain and nausea accompanied by a history of 14 years of chronic abdominal pain and constipation. An abdominal X-ray and subsequent computed tomographic scan showed a severely distended cecum of 9cm with stenosis in the sigmoid. Cecal blow-out was considered highly likely, and, during an emergency laparotomy, an obstructing process was found in the sigmoid. An oncologic resection of the sigmoid was performed with a primary anastomosis and loop ileostomy. A pathological examination revealed a tumor of 4cm in the sigmoid, which contained a tubelike structure with cytogenic stroma and the remains of focal bleeding. These are typical aspects of endometriosis.

Conclusions: Infiltrating endometriosis is an invalidating disease that can be misdiagnosed for a wide range of other diseases. Emergency room physicians and surgeons should be aware that it can present as an acute obstruction and should be considered in diagnosing women of childbearing age. After initial colonoscopy, emergency surgery is the best therapeutic approach if there is a complete obstruction.

Figure 1

Pre-operative imaging studies. X-ray (A) and computed tomographic scans (B, C) of the patient’s abdomen show a significantly inflated cecum and an obstruction in the sigmoid colon with a proximal distension of the colon.

Figure 2

Pathological specimen obtained during sigmoid resection.

Figure 3

Extensive fibrotic foci can be seen with induration in the intestinal wall without mucosal abnormalities.

Figure 4

Microscopically, the tumor had epithelial tubular structures surrounded by arguably cytogenetic stroma and focal hemorrhage remnants suggestive of endometriosis.