Endometriosis is characterized by the presence of endometrial tissue consisting of glands and/or stroma located outside the uterus. Involvement of the terminal ileum is extremely rare. Preoperative distinction of ileal endometriosis from other diseases of the ileocecal region is difficult in terms of clinical presentation, symptomatology, radiological appearance, and surgical and pathological findings. We report a case initially diagnosed as Crohn's disease due to a longstanding diarrhea with subsequent intestinal obstruction, but finally diagnosed as ileal endometriosis by histopathological evaluation after resection of the involved segment.
Endometriosis is a common condition with an unknown etiology that occurs particularly in women of reproductive age and is defined as ectopic foci of benign functional endometrial tissue. Some theories to explain how endometrial tissue moves to other sites include reflux of the endometrial tissue through the fallopian tubes during menstruation which results in implantation of these cells with subsequent growth on serosal surfaces of abdominal and pelvic organs; metaplastic transformation of pluripotential peritoneal mesothelium; migration of these cells through the lymphatic system or via hematogenous spread; development of the endometrial nodules from the metaplasia of mullerian remnants [
A 27-year-old female patient was admitted to our gastroenterology clinic with complaints of abdominal pain and diarrhea of more than 3 months duration. The colonoscopic exam revealed inflammatory changes of the colonic mucosa suggesting inflammatory bowel disease. The computerized tomography showed a solid lesion measuring 2 cm in the left ovary in addition to dilatation of the small bowel segments. Hence, the patient was diagnosed as Crohn's disease and medication with salofalk and steroid treatment was introduced to treat the acute inflammatory attack. However, during her hospitalization period, she began to display progressive nausea and vomiting, suggesting that a small bowel obstruction had developed due to a stricture as a complication of the Crohn's disease. After consultation with the general surgery department on the patient's ileus, it was decided to perform an explorative laparotomy. The patient was explored and dilated small bowel segments, which ended 10 cm proximal to the cecum because a stricture was found (Figure
Image of the involved small bowel segment with endometriosis. (a) The proximal-dilated part of the terminal ileum. (b) The stricture caused by endometriosis. (c) The collapsed distal part of the terminal ileum. (d) Involved regional lymph nodes with endometriosis.
A nest of endometriotic glands and stroma lies in the muscularis propria of the ileum (HE,
Endometriotic glands within lymph node (HE,
Both endometrial epithelial and stromal cells are highlighted by positive ER immunoreactivity (DAB,
ER positivity of endometrial epithelial cells within lymph node (DAB,
Endometriosis of the gastrointestinal tract is a common disorder that, when symptomatic, may be difficult to diagnose accurately. The rectosigmoid area (72%) is the most involved area. Other affected intestinal sites in decreasing order of frequency are the rectovaginal septum (13%), the small bowel (7%), the cecum (4%), and the appendix (3%) [
Intestinal endometriosis may present with a variety of symptoms that are commonly associated with other diseases. While intestinal symptoms may be exacerbated by menses, this association may not always be present as seen in our patient. When it does cause problems, the classic presentation is rectal bleeding at the time of menstruation. However, hemorrhage, intussusceptions, perforation, or small bowel obstruction may also occur [
Small bowel obstruction due to ileal endometriosis is usually only being diagnosed at laparotomy and commonly causes diagnostic confusion with Crohn's disease. Both diseases are characterized grossly by patchy involvement of both the colon and the small intestine with intervening, uninvolved skip areas of the intestine. Enteric endometriosis is usually subserosal with less frequent involvement of the muscularis propria and submucosa. The mucosa is usually intact and uninvolved [
Another characteristic aspect of the present case was the presence of endometrial stroma in regional lymph nodes (LN) of the resected small bowel segment. Endometriod lesions in regional LNs have been described in a number of reports with prevalence rates between 20% and 30% [
Exact diagnosis of cases with no symptoms is difficult before surgery, and ultrasound, CT, and magnetic resonance imaging (MRI) may be of limited benefit. Endoscopic biopsies usually yield insufficient tissue for a definitive pathologic diagnosis as endometriosis involves the deep layers of the bowel wall. Diagnostic laparoscopy is the gold standard in detecting lesions. Biopsy of a suspicious area should be performed for precise diagnosis and for removal of lesions.
The treatment of intestinal endometriosis consists of surgery and drug therapy. Hormone therapies with danazol or gonadotrophin-releasing hormone (GnRH) analogs are used in an attempt to eliminate residual endometriotic cells and reduce the risk of recurrence. However, although surgery with subsequent adjuvant medical therapy can effectively treat endometriosis in many women, the value of some adjuvant treatment strategies has been questioned and recurrence rates remain high [
In conclusion, preoperative distinction of ileal endometriosis from other diseases of the ileocecal region is difficult in terms of clinical presentation, symptomatology, radiological appearances, and surgical and pathological findings. However, ileal endometriosis should always be considered in the differential diagnosis in women of reproductive age.