Rectal endometriosis presenting as toxic megacolon

Abstract

Background:The bowel is the most common site of extragenital endometriosis, with involvement of the locoregional sigmoid colon and anterior rectum seen most often. The clinical presentation varies depending on how soon patients seek medical care, thus requiring changes in management strategies. Endometriosis can cause a life-threatening surgical emergency with progressive obliteration of the bowel lumen leading to obstruction and late complications including toxic megacolon and transmural necrosis. Case presentation: We report the case of a 41-year-old woman presenting with an acute abdomen and complete large bowel obstruction complicated by sepsis and toxic megacolon. The patient underwent emergency total colectomy with ileostomy. Medical history was significant for chronic, vague, and episodic lower abdominal pain selfmedicated with herbal tea and laxatives. Pathologic examination demonstrated colonic endometriosis within the bowel wall as the cause of obstruction, ischemia, and transmural necrosis. Conclusions: Although a rare clinical entity, this case highlights two important points. First, it demonstrates the value of performing proper and complete clinical work up to rule out or in all possible causes of colonic obstruction, including intestinal endometriosis. Second, it suggests a potential benefit of a formalized multidisciplinary approach, including surgery, in the management of medically unresponsive endometriosis. In conclusion, this case shows that endometriosis can cause life-threatening colonic obstruction in women of childbearing age. Prompt early intervention is warranted, particularly when obstruction is only partial and ischemia has not supervened, to conceivably prevent the development of a toxic megacolon requiring colectomy and avoid late complications.

A Case of Rectal Endometriosis Misdiagnosed as Rectal Malignancy on Three Colonoscopies and Biopsies Sharing a Combined Literature Review

“…2010 37 36 Cecal Ileocolic Intussusception Laparoscopic debulking of the endometriosis, and right hemicolectomy Yes Marklund A. 2019 38 30 Rectosigmoid colon 2 weeks interval abdominal pain and a 4 days’ history of obstipation Neoadjuvant treatment that included radiotherapy and chemotherapy, later do rectum and a bilateral salpingo-oophorectomy No Alvarado LER.2021 39 41 Rectal Complete large bowel obstruction complicated by sepsis and toxic megacolon Total colectomy with ileostomy No Allan Z. 2018 40 37 Large bowel Large bowel obstruction Laparoscopic wedge resection of rectosigmoid tumour with primary anastomo-sis and endoscopic decompression Yes Garg NK.2009 41 44 Colon Colonic perforation A proximal colostomy was performed and the endometriotic mass resected Yes Lee M. 2021 42 35 At the cecum near the appendiceal orifice Fetal demise and gastrointestinal hemorrhage Symptomatic treatment such as blood transfusion and have a colonoscopy after delivery No Aragone L. 2023 43 39 Appendiceal A week of abdominal pain was diagnosed as appendicitis Appendectomy No Alabbas H. 2019 44 Reports not prompted Small Bowel Recurrent semi-obstructive symptoms Right hemico...…”

Endometriosis as an Uncommon Cause of Intestinal Obstruction—A Comprehensive Literature Review

“…The mean age of patients diagnosed with LBO due to rectal endometriosis (11 patients) [27,[89][90][91][92][93][94][95][96][97] was 38.45, with a minimum of 26 and a maximum of 50. Nine underwent emergency surgery, consisting of a total colectomy in one patient, a colostomy without any type of resection in three patients, anterior rectal resection in three patients, and rectosigmoid resection in four patients.…”