Intestinal Obstruction as Manifestation of a Multifocal Colonic Endometriosis
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Image of the Month Intestinal Obstruction as Manifestation of a Multifocal Colonic Endometriosis GINO CASELLI,* CECILIA BESA, ‡ and DAHIANA PULGAR* *Unit of Colorectal Surgery, Department of Digestive Surgery, Pontifical Catholic University of Chile, Santiago; and ‡ Department of Radiology, Pontifical Catholic University of Chile, Santiago, Chile A 44-year-old woman was admitted with history of hypogas- tric pain, absence of flatus, and abdominal cramps. Phys- ical examination revealed abdominal distention and generalized tenderness. Rectal examination showed soft stools in the am- pulla. Laboratory tests showed anemia (24.6%), leukocytosis (19,300/mm 3 ), and left shift. Axial and curved reconstruction contrast-enhanced computed tomography images show 3 ex- trinsic solid masses (arrowheads) in the proximal and midsig- moid colon and rectosigmoid junction causing large-bowel ob- struction. Also noted, cul-de-sac endometriotic adhesions with secondary fixed ovaries toward the midline (“kissing ovary” sign) (asterisks), secondary probably to endometriotic implants (Figure A–B). A low midline laparotomy was performed. A dilated colon proximal to the rectosigmoid junction was found with 3 constrictive lesions affecting the proximal, midsigmoid colon and the rectosigmoid junction (Figure C). Macroscopic view of 3 intramucosal colonic endometriosis without erosion of the mucosa (arrows). Histologic view depicts the presence of ectopic foci of endometrial-type gland and stroma in the sub- mucosa (black arrow). A Hartmann procedure was performed. Histologic examination demonstrated extensive endometriosis of submucosa, muscular propia and serosa of the colon (black arrow) with a multifocal anular stenosis (Figure D). The patient had an uneventful recovery and was discharged awaiting for colostomy closure. Endometriosis is the presence of endometrial stroma and glands outside the uterine cavity. The intestine is affected in 5% to 10% of the cases, with the rectosigmoid colon most com- monly involved. Less frequent sites are appendix, cecum, and distal ileum. 1 Intestinal endometriosis is often asymptomatic and diagnosed incidentally at laparotomy, mimicking a colo- rectal neoplasia or an intestinal obstruction. Endometriotic implants are typically located on the antimesenteric surface of the bowel and usually serosal, but can erode through the sub- serosal layers; an important feature is that the mucosa is free of disease. Diagnosis of bowel endometriosis is challenging and suggested by specific symptoms and imaging findings. Various Conflicts of Interest The authors disclose no conflicts. © 2011 by the AGA Institute 1542-3565/$36.00 doi:10.1016/j.cgh.2011.04.021 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:e90 – e91
Transcript of Intestinal Obstruction as Manifestation of a Multifocal Colonic Endometriosis
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Image of the Month
Intestinal Obstruction as Manifestation of a Multifocal ColonicEndometriosis
GINO CASELLI,* CECILIA BESA,‡ and DAHIANA PULGAR*‡
*Unit of Colorectal Surgery, Department of Digestive Surgery, Pontifical Catholic University of Chile, Santiago; and Department of Radiology, Pontifical Catholicniversity of Chile, Santiago, Chile
A44-year-old woman was admitted with history of hypogas-tric pain, absence of flatus, and abdominal cramps. Phys-
cal examination revealed abdominal distention and generalizedenderness. Rectal examination showed soft stools in the am-ulla. Laboratory tests showed anemia (24.6%), leukocytosis
19,300/mm3), and left shift. Axial and curved reconstructionontrast-enhanced computed tomography images show 3 ex-rinsic solid masses (arrowheads) in the proximal and midsig-
oid colon and rectosigmoid junction causing large-bowel ob-truction. Also noted, cul-de-sac endometriotic adhesions withecondary fixed ovaries toward the midline (“kissing ovary”ign) (asterisks), secondary probably to endometriotic implantsFigure A–B). A low midline laparotomy was performed. Ailated colon proximal to the rectosigmoid junction was foundith 3 constrictive lesions affecting the proximal, midsigmoid
olon and the rectosigmoid junction (Figure C). Macroscopiciew of 3 intramucosal colonic endometriosis without erosionf the mucosa (arrows). Histologic view depicts the presence ofctopic foci of endometrial-type gland and stroma in the sub-ucosa (black arrow). A Hartmann procedure was performed.istologic examination demonstrated extensive endometriosis
f submucosa, muscular propia and serosa of the colon (black
arrow) with a multifocal anular stenosis (Figure D). The patienthad an uneventful recovery and was discharged awaiting forcolostomy closure.
Endometriosis is the presence of endometrial stroma andglands outside the uterine cavity. The intestine is affected in 5%to 10% of the cases, with the rectosigmoid colon most com-monly involved. Less frequent sites are appendix, cecum, anddistal ileum.1 Intestinal endometriosis is often asymptomaticand diagnosed incidentally at laparotomy, mimicking a colo-rectal neoplasia or an intestinal obstruction. Endometrioticimplants are typically located on the antimesenteric surface ofthe bowel and usually serosal, but can erode through the sub-serosal layers; an important feature is that the mucosa is free ofdisease. Diagnosis of bowel endometriosis is challenging andsuggested by specific symptoms and imaging findings. Various
Conflicts of InterestThe authors disclose no conflicts.
© 2011 by the AGA Institute1542-3565/$36.00
doi:10.1016/j.cgh.2011.04.021
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9:e90–e91
September 2011 IMAGE OF THE MONTH e91
imaging techniques have been proposed for the diagnosis ofbowel endometriosis, but all have limitations. Double-contrastbarium enema has a limited luminal depiction, but can showendometriotic nodules as an extrinsic intestinal mass in asso-ciation with mucosal fine crenulation, a highly suggestive sign,having a sensitivity of 88.4% and specificity of 93.0%.1 Multide-tector computed tomography enteroclysis or coloclysis can ef-fectively depict the presence of endometriotic lesions with pos-itive enhancement contiguous to or penetrating the bowel wall,with a sensitivity of 98.7% and a specificity of 100% describedfor multidetector computed tomography enteroclisis.2 Bowelinvolvement is diagnosed on magnetic resonance imaging asretractable nodular formations adhering to the bowel wall,which are hypointense on T2-weighted images and usuallyshow gadolinium enhancement and sometimes the presence ofpunctate hyperintense foci of hemorrhage. A sensitivity of 84%and specificity of 99% has been reported for magnetic resonance
imaging, and the coexistence with other signs of deep pelvicendometriosis can suggest the diagnosis in the correct clinicalscenario.3 There are no guidelines for the management of colo-rectal endometriosis. Hormonal suppression is indicated fornonocclusive intestinal disease, causing regression of the im-plants. Intestinal resection is reserved for patients with obstruc-tive symptoms. Colonic endometriosis should be considered asdifferential diagnosis in premenopausal women with symptomsof intestinal obstruction.
References1. Faccioli N, Manfredi R, Mainardi P, et al. Barium enema evaluation
of colonic involvement in endometriosis. AJR Am J Roentgenol2008;190:1050–1054.
2. Biscaldi E, Ferrero S, Fulcheri E, et al. Multislice CT enteroclysis inthe diagnosis of bowel endometriosis. Eur Radiol 2007;17:211–219.
3. Kinkel K, Frei KA, Balleyguier C, et al. Diagnosis of endometriosis
with imaging: a review. Eur Radiol 2006;16:285–298.
