Small bowel obstruction due to an endometriotic ileal stricture with associated appendiceal endometriosis: A case report and systematic review of the literature

Abstract

Introduction: Endometriosis is defined as the presence of functional ectopic endometrial tissue outside the uterine cavity. It rarely involves the small bowel and obstruction due to the same is highly uncommon. Preoperative diagnosis is difficult based on clinical and radiological studies. Diagnosis can be confirmed only on histopathological examination of the surgically resected specimen.

Presentation of case: A 44 years old lady presented with repeated episodes of abdominal pain, non bilious vomiting and diarrhea. She also gave history of abdominal pain during every menstruation. She had diffuse abdominal tenderness and the computed tomography showed a concentric infective/inflammatory thickening of the distal ileum. Colonoscopy confirmed a tight distal ileal stricture After a failed trial of conservative management, she underwent a laparoscopic right hemicolectomy. The histopathological examination revealed multiple endometriotic foci in the ileum and the appendix.

Discussion: Ileal endometriosis presenting as obstruction is uncommon and very few cases have been reported thus far. The symptoms are usually cyclical but may later become continuous with the progression of the disease. Preoperative diagnostic dilemma is due to the clinical and the radiological similarities to inflammatory, infective and irritable bowel diseases.

Conclusion: Ours is probably the first case of small bowel obstruction due to ileal and appendiceal endometriosis that was managed with laparoscopic right hemicolectomy. We highlight the preoperative diagnostic dilemma and the progression of the cyclical symptoms. Thus, endometriosis must be considered in cases of small bowel obstruction in women in the reproductive age group as a rare cause.

Keywords: Appendiceal endometriosis; Ileal endometriosis; Ileal stricture; Right hemicolectomy.

Fig. 1

CT showing concentric thickening of the distal ileum with significant luminal narrowing of the ileocaecal junction and terminal short segment of ileum with proximal ileal dilatation. No complete mechanical obstruction seen. Interbowel fluid present in pelvis.

Fig. 2

A—Deflated ballon after attempted stricture dilatation, B—failure of ballon dilatation.

Fig. 3

A—Laparoscopic view of the ileal stricture, B—laparoscopic view of the appendicular mass at the tip of the appendix, C—hemorrhagic ascites, D—endobag with specimen (arrow pointing towards appendicular mass).

Fig. 4

A—Ileum with endometriosis, B—appendix with endometriosis, C—ER positive, D—PR positive, E—CD 10 positive.