Tech Coloproctol (2011) 15 (Suppl 1):S105–S106 DOI 10.1007/s10151-011-0743-z
Rectal endometriosis: a case report V. N. Papadopoulos • D. Panagiotou • S. Panidis • A. Mekras • K. Fotiadis • S. Netta • I. Marianou • A. Michalopoulos
Published online: 2 September 2011 Ó Springer-Verlag 2011
Abstract We present the case of a 45-year-old female patient who was admitted with a history of pelvic pain, constipation, and dysmenorrhea. CT scan and u/s images revealed cholelithiasis, benign nodular hyperplasia of segment IV of the liver and uterine fibromyoma. During laparotomy, firm adhesions between the posterior wall of the uterus and the rectum were found and the incisional biopsy reveals an undifferentiated adenocarcinoma. Then, total resection of the uterus was performed with en block resection of the adherent part of the rectum and part of the posterior wall of the vagina. The final histopathological report showed the presence of uterine fibromyoma, nodular hyperplasia of the liver and rectal endometriosis without any sign of malignancy. The patient after 5 years of follow up remains healthy. Rectal endometriosis represents an uncommon localization of pelvic endometriosis where the symptoms and clinical findings are non-specific making the definitive preoperative diagnosis difficult. Endometriosis should be included in the differential diagnosis of chronic pelvic pain in combination with defecation disorders in female patients of reproductive age. Keywords Endometriosis Rectal endometriosis Chronic pelvic pain
V. N. Papadopoulos (&) D. Panagiotou S. Panidis A. Mekras K. Fotiadis S. Netta I. Marianou A. Michalopoulos 1st Propedeutic Surgical Department, Aristotle’s University of Thessaloniki, A.H.E.P.A. Hospital, T. Oikonomidi 21, 551 31 Thessaloniki, Kalamaria, Greece e-mail:
[email protected]
Case report A 45-year-old female Caucasian patient was admitted with a history of chronic pain in her right iliac fossa, constipation, and dysmenorrhea. The medical history of the patient was free and during physical examination, a mild tenderness of the right iliac fossa and right upper quadrant was found. Blood tests and CXR were normal, while abdominal ultrasound revealed cholelithiasis. CT scan showed the presence of uterine fibromyoma and nodular hyperplasia of segment IV of the liver. The patient underwent an exploratory laparotomy. Cholecystectomy and resection of the hepatic hyperplasia of section IV using Starion’s Thermal Ligating Shears were performed. During mobilization of the uterus, it was noticed that posterior wall of the uterus was firmly attached on to the rectum. Segments of this infiltration were taken, and the biopsy revealed the presence of undifferentiated adenocarcinoma. Total resection of the uterus was performed with en block resection of the adherent part of the rectum and part of the posterior wall of the vagina. The postoperative period was uneventful, and the patient was discharged on the 9th postoperative day. The final pathological report showed the presence of uterine fibromyoma, nodular hyperplasia of the liver and rectal endometriosis without any sign of malignancy. The patient after 5 years of follow up remains healthy and free of any symptoms.
Discussion Signs and symptoms of intestinal endometriosis are nonspecific and, occasionally, mimick malignancy. The disease can be asymptomatic or appear with nausea, chronic pelvic pain, constipation, diarrhea, pain during defecation,
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hemorrhage. Signs of bowel obstruction or perforation can be observed [1–8]. Not often, bleeding within the lesions can cause hemoperitoneum and acute abdominal pain. Malignant exchange and development of endometrial adenocarcinoma or endometrial stroma cell sarcoma has been described within the enteric endometrial foci [9]. In the presented case, the patient’s symptoms were not specific making the precise preoperative diagnosis difficult since the findings of the usual imaging tests are non-specific for the disease and the biopsy during operation was misleading. Patient’s symptoms evaluation by CT scan images can reveal regional thickness of rectum wall, the presence of an unusual pelvic mass, or imaging findings of bowel obstruction. It is obvious that the differential diagnosis from rectum adenocarcinoma is almost impossible. During endoscopy of the large bowel, areas with stenosis, lesions with luminal appearance, or foci of mucosal hyperemia can be observed. Biopsies do not contribute in diagnosis since the lesions are located in subserosa or serosa while the enteric mucosa appears intact [10]. Due to the fact that precise preoperative diagnosis and differential diagnosis from malignant disease are extremely difficult, surgical approach seems to be of vital importance in most cases of rectum endometriosis. Permanent solution provides the performance of total uterus resection in combination with en block resection of the affected rectal segment and any other evident lesion of pelvic endometriosis.
Conclusion Rectal endometriosis should be included in the differential diagnosis of chronic pelvic pain in combination with defecation disorders in female patients of reproductive age.
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Tech Coloproctol (2011) 15 (Suppl 1):S105–S106 Conflict of interest The authors certify that there is no actual or potential conflict of interest in relation to this article.
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