Insidious perforation of the rectum by a fallopian tube: the need to keep 'an open mind' when dealing with deep infiltrating endometriosis (DIE)

Abstract

Endometriosis is a benign chronic disease which can have different degrees of severity and can potentially affect any organ. Intestinal endometriosis occurs in 3%â€"37% of the cases, being more frequent in the rectosigmoid transition. Transmural involvement of intestinal endometriosis is extremely rare and is usually associated with recurrent abdominal pain. Due to the cyclical hormone influence, endometriosis implants may infiltrate the deeper layers of the intestinal wall and may lead to bowel obstruction or perforation. We present a case of transmural perforation of the rectum wall by an adjacent organ (left fallopian tube) that occurred insidiously in a patient with deep infiltrative endometriosis. A complete set of images is presented, regarding the preoperative, intraoperative and postoperative findings.

Keywords: Gastrointestinal Surgery; Obstetrics And Gynaecology; Reproductive Medicine.

Figure 1

MRI T2-weighted sagittal image shows an exofitic image originated in the left adnexal region of heterogeneous appearance with poorly defined limits and which seemed to creep into the lumen of the sigmoid colon. It also revealed a thickening of the rectovaginal fascia and the uterosacral ligaments.

Figure 2

Colonoscopy confirmed the presence of a sessile luminal lesion with 3.5 cm, 12 cm from the anal margin. A biopsy was performed and histological results revealed an inflammatory polyp of the colon.

Figure 3

Left adnexa blocked by thick adherences to the rectosigmoid transition.

Figure 4

Hole in the anterior wall of the rectum after removal of the distal portion of the tube (pavilion) that pierced the entire wall thickness up to the lumen of the rectum.

Figure 5

Anterior discoid resection of the rectum.

Figure 6

MRI T2-weighted sagittal figure 2 months after surgery. No endoluminal lesions were found.