Twisted Troubles: A Rare Case of Intestinal Obstruction Due to Endometriosis and a Review of the Literature

Abstract

Background and objectives: Intestinal endometriosis is an exceptionally rare cause of intestinal obstruction. This case report and literature review aim to highlight the clinical presentation, diagnostic challenges, and surgical management of this condition.

Materials and methods: We report the case of a 50-year-old female patient who presented diffuse abdominal pain, nausea, vomiting, a distended abdomen, and an absence of intestinal transit for gas and faeces. Initial symptoms included flatulence and constipation, which gradually worsened for two months prior to the patient's hospital admission, leading to acute intestinal obstruction. Diagnostic investigations, including blood tests, ultrasound (USG), X-ray, and a contrast-enhanced computer tomography (CT) scan, revealed significant small bowel dilatation and an ileal volvulus. The patient underwent urgent hydro-electrolytic and metabolic rebalancing followed by a median laparotomy surgical procedure. Intraoperative findings included a distended small intestine and an obstructive ileal volvulus, and required an 8 cm segmental enterectomy and terminal ileostomy.

Results: Postoperative recovery was slow but favourable, with a gradual digestive tolerance. Histopathological examination of the resected ileum revealed intestinal endometriosis characterized by a fibro-conjunctive reaction and nonspecific chronic active inflammation. Five months later, the patient underwent a successful reversal of the ileostomy with a mechanical lateral anastomosis of the cecum and ileum, resulting in a favourable postoperative course.

Conclusions: This case underscores the importance of considering intestinal endometriosis in women presenting with unexplained gastrointestinal symptoms and highlights the need for timely surgical intervention and careful postoperative management. Further research is required to better understand the pathophysiology and optimal treatment strategies for intestinal endometriosis.

Keywords: endometriosis; extragenital; ileo-caecal anastomosis; intestinal occlusion; volvulus.

Figure 1

PRISMA flow diagram for the results. * studies are not relevant for the present review. ** studies do not help us to provide an answer to the current research. *** unable to find the full text of the study. **** Reason 1—study on animals/Reason 2—wrong setting/Reason 3—research question not relevant.

Figure 2

Ultrasound image of the volvulus—intestine twists around itself and its mesentery (red arrow), “whirlpool sign” (green arrow).

Figure 3

CT image of the intestinal volvulus—“whirlpool sign” (red arrow), air loops (green arrow).

Figure 4

CT image of multiple dilated loops of small bowel with air (red arrows), and fluid (green arrow).

Figure 5

CT image of the “Whirlpool sign”— spiralling appearance of the mesenteric vessels (red arrow) suggestive of a small bowel volvulus.

Figure 6

Volvulus of the small intestine.

Figure 7

The degree of distension of the small intestine.

Figure 8

The appearance of the ileal loop before devolution.

Figure 9

The appearance of the ileal loop after devolution.

Figure 10

The small intestine after decompression.

Figure 11

Enterectomy piece, with evidence of tumor injury.

Figure 12

(A) Parietal endometriosis (red arrow) of the intestinal wall with normal intestinal mucosa (H&E stain; original magnification 40×); (B) Clusters of endometrial glands and stroma (green arrow) into the muscularis propria of the intestinal wall with discrete inflammation (H&E; original magnification 200×).