Glit, 1988,29, 1112-1115

Case report

Endometriosis and the gutN J PARR, C MURPIHY, S IIOLT, H ZAKHOUR, AND R B CROSBIE

Fromti t1e D)ep)artnitiett.s ol Suirg(ry1atid Pathology, Arrowe lPark Hos,p1ital, Upton, Wirral atnd Delpartmtletnt ofSur,gery, Broa(dgreeti Hos.)pital, Lile(rlpool

SIJMMARY Six patients with endometriosis involving the intestine are described and illustrate thevariety ofsymptoms which may occur in this condition, many ofwhich are frequently associated withthe more common gastrointestinal illnesses. A correct preoperative diagnosis based on history,clinical examination, radiology, and endoscopy may be difficult to make, and when first discoveredat laparotomy endometriosis can easily be mistaken for other inflammatory, or neoplastic processes.A histological diagnosis should always be made before definitive treatment.

Although endometriosis most frequently involves the ; ; [femrale reproductive organs, it has also been des-cribed in many other sites throughout the body.Despite this, little attention is paid to endometriosisin most texts of gastroenterology. We have recentlytreated a number of women with intestinal endo- Imetriosis and the cases described in this articleillustrate the wide variety of presentations which mayoccur in this condition.

PATIENT 1A 28 year old woman presented with a painfulperianal swelling of six days duration. This had beentreated initially with antibiotics. Her last menstrualperiod had started 12 days previously. There was nopast history of gastrointestinal symptoms. She wastaken to theatre for drainage of a perianal abscess. Atoperation a thick walled lesion was excised, which atthat time was thought to be a chronic acbscess.Sigmoidoscopy revealed no other abnormality.When reviewed in clinic one month later, shevolunteered that there had been considerablehaemorrhage from the cavity during her most recentmenstrual period. Microscopy of the perianal lesionshowed chronically inflamed fibrous tissue, contain-ing several foci of endometrial glands surrounded byendometrial stroma. The lesion eventually healedwithout further surgical intervention.

Addr.ss tor correspondence: Mr N .1 P.lrr I)Deirtmint o)f Sitrgery,, ArrowcP'rk lospital. Wirrzil. 149 51'!1`- Fig. 1 Barium enema (positive image) showing a strictureRceiced for pubhliatiorn March1989. in thle lowersigmoid colon.

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Fig. 2 Photomicrograph oJ lar~ge bowelsliowing endometrial glands and stromapresenft w4ithin submucwosa.

PATIENT 2A 37 year old woman presented witlh a history ofincreasing pain on defecation. She claimed thatbecause of the discomfort she had become reluctantto open her bowels more than once per week.Examination revealed a 4x2 cm rubbery mass in therectovaginal septum. Sigmoidoscopy showed nomucosal abnormality and a Tru-cut biopsy of themass was taken. Histology showed haemosiderinpigmentation throughout areas of connective tissue,but no specific pathology. A repeat sigmoidoscopyrevealed a small erythematous lesion at 2 cm abovethe anal verge. The histology from a further biopsyshowed islands of endometrial tissue. The patientwas started on danazol and her symptoms haveimproved but not resolved completely.

PATIE Ni 3A 46 year old woman was referred by a gastro-enterologist after colonoscopy had revealed a tightstricture in the sigmoid colon. She had presented tohim with a four month history of spasmodic upperabdominal pain, aggravated by feeding and associ-ated with belching and abdominal gurgling. These

symptoms were initially investigated by gastroscopy.Three years ago she had undergone a hyster-

ectomy, and shortly afterwards had developedvaginal endometriosis. At that time she also began toexperience lower abdominal pain, bloating, constipa-tion, and occasional bleeding per rectum. Hergynaecologist had arranged a barium enema, duringthe last year, which had shown a sigmoid stricture(Fig. 1) and this was attributed to endometriosis. Shehad been treated with danazol, but this was with-drawn after two months because of side effects.At laparotomy there was a rigid stricture in the

lower sigmoid colon, with proximal distension of thebowel. The left ovary was fibrosed and the rightcontained multiple chocolate cysts. The stricture wasresected and both ovaries were removed. At micro-scopy the large bowel mucosa was intact. Thesubmucosa contained numerous foci of endometrio-sis (Fig. 2), with surrounding fibrosis and evidence ofold haemorrhage. l ler symptoms were relieved.

PATIIEN 4A 34 year old woman presented with acute right sidedabdominal pain. It was 21 days since starting her last

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Parr, Murphy, Holt, Zakhouir, and Crosbie

menstrual period, with a normal cycle of 28 days.Over the past three years she had intermittantlyexperienced similar although less severe pain, andthis had led to two hospital admissions elsewhere.One of these coincided with menstruation, but theother was during the mid-cycle. A barium enema hadrevealed no abnormality.On abdominal examination she was markedly

tender with guarding in the right iliac fossa. Atoperation the terminal ileum and caecum werefibrosed, with multiple strictures and dense adhe-sions. An ileocaecal resection was carried out. Micro-scopy of the specimen revealed endometrial glandsand stroma within the submucosa, muscularis propriaand serosa. There was also an extension of theendometrial stroma into the lamina propria (Fig. 3).

PATIENT 5A 49 year old woman presented with generalisedperitonitis. Over the past 18 months she had experi-enced recurrent episodes of diffuse colicky abdomi-nal pain, radiating to her back and aggravated bymeals. Her general practitioner had arranged aGraham's test which had shown no abnormality. Forthree weeks before admission her symptoms hadworsened, with frequent vomiting, and loss ofweight.At laparotomy there were dense pelvic adhesions.

A large inflammatory mass involved the terminalileum, caecum, right ovary, and uterus. The smallbowel mesentery was grossly thickened and the mostlikely diagnosis was thought to be Crohn's disease.Macroscopically the resected ileocaecal specimenshowed a tight ileal stricture, with thickening of thebowel wall and serosal exudate. Microscopicallythere was no mucosal ulceration, the submucosawas oedematous and the bowel wall was infiltrated byboth polymorphs and chronic inflammatory cells.Occasional endometriotic foci were seen in thesubmucosa, with multiple foci in the outer bowelwall. There was no evidence of epithelioid cellgranuloma formation.

PATIENT 6A 30 year old woman presented with sudden onset ofabdominal pain, three days after starting a menstrualperiod. Examination revealed generalised peri-tonitis. Three months previously she had been admit-ted and observed with an episode of lower abdominalpain. At that time her bowel habit had recentlybecome irregular and she had complained of bloat-ing. A small bowel meal had been arranged, whichwas normal.At laparotomy there was a 10 cm chocolate cyst,

which had ruptured. The cyst was densely adherentto the rectum, with additional adhesions to the ileum.

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Fig. 3 Photomicrograph oJ caecal mucosa showingendometrial stroma replacing lamina propria. Inset: detail ofboxed area with endometrial glands surrounded by stroma.

Histology confirmed that the cyst was lined byendometrial type of epithelium, with adjacent endo-metrial stroma and a thick fibrous wall.

Discussion

It has long been established that endometriosis mayinvolve the lower bowel,' but there is perhaps littlegeneral awareness as to its diversity of presentations.Although most of the presentations noted in thisarticle have previously been described, we believethat the variety of symptoms associated with thecondition and some of the difficulties which arise inits management, are well illustrated by these casereports.

Studying the summary of presentations in theTable it is obvious that each may be produced byother commoner gastrointestinal illnesses. Thewomen were in the third, fourth, and fifth decadesand particularly in the older age group one mightsuspect alternative diagnoses. An accompanying

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Endo0nwetriosis and the glit 1115

Table Sluntnminor of f ,tiogfco!ttr(. of ihlto.eindotnetriosis iil sixi)/)I1ills

Pcrialliabsccss'. with haeniorrlhaocPainful defecationRectovaginal massConstipationIrregular bowcl habitBleeding pcr rectumBloatingBelchingVomitingWeight lossColicky aibdominal painAcutc pain in right iliac fossaGeneraliscd peritonitis

gynaecological history of acquired dysmenorrhoea,dysparunia, menorrhagia, and sterility shouldsuggest the possibility of intestinal endometriosis,but were absent in most of these cases. Similarly, anexacerbation of symptoms at the time of menstrua-tion did occur in some patients, but this associationwas often realised retrospectively. In others therewas clearly no such association. Several women hadundergone previous radiological and endoscopicinvestigations, as other diseases had been suspectedby both ourselves and other clinicians. In patient 3,we believe that the radiological appearance could bemistaken for a neoplasm. Radiological differentia-tion between a small rectal cancer and endometriosiscan be impossible, although the presence of a longfilling defect and the absence of mucosal involvementare thought to be suggestive of endometriosis.'Where a lesion was identified, initial Tru-cut biopsywas unhelpful and needed to be repeated. Theabsence of mucosal ulceration may make accuratetargeting of colonic biopsies difficult and a smallbiopsy specimen could miss endometriotic foci andreveal only fibrosis. Nevertheless, this combinationmight alert one to the possibility of endometriosis.A more widespread use of laparoscopy might also

lead to earlier diagnosis of the condition. A trial ofmedical treatment would then be appropriate. Thereis some evidence, however, to suggest that conserva-tive surgery offers a better chance of subsequentpregnancy, and this should be taken into account.Danazol is at present the first line of medicaltreatment, although its androgenic side effects can beparticularly distressing in some young women.Recently buserilin has been reported to be equallyefficatious, with less androgenic effects, but produc-ing a higher incidence of flushing and vaginal dry-ness.4 Longer term studies with this agent areawaited.

When discovered at laparotomy we found that itwas difficult to make a diagnosis of endometriosiswith confidence. This has also been the experience ofother general surgeons and the use of frozen sectionhas been proposed. Is a correct diagnosis essential atthe time of operation? When the condition hasprogressed to the stage of intestinal obstruction thenlocal resection is required, but earlier lesions can betreated by partial excision of the bowel wall." If thepatient is approaching the menopalse or whenpreservation of fertility is unimportant, an oophorec-tomy will prevent a recurrence of endometriosis.Oophorectomy can also restore patency of the bowelwhen obstruction is incomplete.' Thus, a provisionaldiagnosis of a bowel neoplasm can lead to excessivelyradical surgery and to the morbidity of an intestinalanastamosis which may not be required." Second,failure to undertake an oophorectomy when indi-cated, may result in the patient eventually requiringfurther surgery.

In summary, endometriosis of the bowel canpresent with a wide variety of symptoms which aremore commonly associated with other diseases.-Adiagnosis based on history, clinical examination,endoscopy or radiology may be difficult to make. Inthis respect a tissue diagnosis is of paramount import-ance, and biopsies may need to be repeated. Mis-taken diagnoses may also occur at laparotomy. Ifdoubt arises at the time of surgery then a frozensection diagnosis should be sought. A wider aware-ness of the condition in premenopausal women mightlead to earlier medical treatment and to the correctoperative management.

References

I Cullen TS. The distribution of adenomyomras containinguterine mucosa. Annii Slrg¢ 1920; 1: 215-83.

2 Burns FJ. Endometriosis of the intestines. )iN (/olonRec tiutm 1967; 10: 344-6.

3 Andrcws WC. Medical versus surgical treattmcnt ofendometriosis. C/in Obstet (Knaecol 1980; 23: 917-24.

4 Mcatta WH, Shaw RW. A comparative study betweenbuscrclin and danazol in the treatment of endometriosis.BrJ (lini Pract 1987; 41: Isupplementl 69-72.

5 Townell NH. Vanderwalt JD. Jaggcr GM. Intestiniliendometriosis: dliagnosis aind management. Br J Sl.rg1984; 71: 629-30.

6 Gray LA. Endometriosis of the bowcl: role of howelrcsection, superficial excision aind oophorectomy in treiat-ment. Annii Slurg 1973; 177: 580-7.

7 Korn GW. Savaige PT. Endometrioma of the rectum. BrJSiurg 1957; 44: 588-9 1.

8 Britton 1)C. Thomsonl JPS. Rectal endometriosis. J R(oll/Slrgt Edlinb 1979; 24: 3t)-3.

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