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Keywords
Gastrointestinal Endometriosis,
Colonic Obstruction
Introduction
Colonic endometriosis can have variable presentations and the diagnosis is often delayed. Seat belt trauma to the abdominal organs has been reported and could result in strictures of the small and large bowels. We are reporting a case of colonic stricturing caused by endometriosis that we believe was precipitated by seat belt trauma.
Case/Body
A 26-year-old previously healthy female patient presented with constipation and abdominal pain three months after being involved in a motor vehicle accident where she sustained seat belt trauma. She reported symptoms of abdominal pain and bleeding per rectum along with peri-umbilical bluish discoloration at the time of her menstrual period for the last month prior to her presentation. She denied any previous pelvic pain, dyspareunia, menstrual cycle irregularities or bleeding per rectum and had regular soft bowel movements daily. Her previous annual physical examinations included bimanual pelvic exams and pap smears that were within normal limits. She was initially treated for Crohn’s disease based on colonoscopy findings of mucosal edema and erythema in a short segment of the colon. She had no response to treatment and later was sent to our institution for a second opinion. Before completing her evaluation, she was hospitalized with partial colonic obstruction. A barium enema showed a sigmoid stricture with proximal colonic dilation (Figure 1). Follow-up colonoscopy revealed a non-inflamed stricture measuring approximately 6-cm (Figure 2). The stricture allowed passage of a small caliber scope, which revealed a dilated colon with a large amount of retained stool above the stricture. Biopsies from the site were normal. The patient underwent exploratory laparatomy with segmental colonic resection (Figure 3) and had an uneventful post-operative course. Histological examination confirmed the presence of endometrial-type glands extending circumferentially around the sigmoid colon and invading the submucosa, thus causing the stricture (Figures. 4a and b). The patient had no recurrence of her symptoms after the surgery on subsequent follow up.
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Figure 1 |
Figure 2 |
Figure 3 |
Discussion
Endometriosis is a common gynecological diagnosis1. Gastrointestinal (GI) involvement, though, is less common, occurring in up to 10-15% of the cases 2. Among women with intestinal endometriosis, the rectum and sigmoid colon are the most commonly involved areas (75–90%)(see table).3,4 Other parts of the bowel less commonly affected are the distal ileum (2–16%), and appendix (3–18%).2 Although typically a disease of the young, GI endometriosis can also affect postmenopausal women.5 On average, the age at time of diagnosis for GI endometriosis is 10 years older than for patients with pelvic endometriosis. Classically, the hallmark symptom of GI endometriosis is rectal bleeding during menstruation; however, intussusception, hemorrhage, perforation, small bowel or colonic obstruction have also been reported.6,7
While the serosa and the muscularis propria are usually grossly involved, the mucosa is rarely affected.8,9 Because of this, the mucosa is frequently normal or shows minimal changes endoscopically. Histologic examination of superficial, endoscopically obtained biopsy material may reveal only nonspecific, chronic changes which, in the absence of diagnostic endometriotic glands and stroma, may be misinterpreted as other disease entities such as inflammatory bowel disease.10 Therefore, the etiology of bowel obstruction is usually revealed at the time of surgical resection.11 Due to the atypical presentations of GI endometriosis, diagnosis can be a challenge and is often delayed for several years.12 Colon x-ray, endoscopy, endoscopic ultrasound and laparoscopy all play a role in the diagnosis once clinically suspected.
Blunt abdominal trauma to the bowel from seat belt use has been previously described. In one study, gastrointestinal tract injuries (stomach, small bowel, colon and rectum) were significantly more frequent in belted vs. unbelted patients (3.4% vs. 1.8%, respectively).13 Several case reports have been published where seat belt trauma was believed to have caused focal ischemia to the bowel resulting in small and large bowel stenosis.14,15,16, 17-19 Although the role of seat-belt trauma in triggering the endometriosis remains unclear in our case, we suggest that blunt abdominal trauma triggered the spread of the endometriosis outside the uterine cavity and into adjacent pelvic structures causing the obstruction. We understand that proving this association is difficult, but complete lack of symptoms to suggest colonic endometriosis prior to the abdominal trauma makes this assumption more plausible.
GI Site |
Prevalence |
Rectosigmoid |
72% |
Rectvaginal Septum |
14% |
Cecum |
4% |
Small Bowel |
10% |
References
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17. Hardacre, J.M., 2nd, et al. Delayed onset of intestinal obstruction in children after unrecognized seat belt injury. J Pediatr Surg, 1990. 25(9): p. 967-8; discussion 968-9
18. Lynch, J.M., et al. Intestinal stricture following seat belt injury in children. J Pediatr Surg, 1996. 31(10): p. 1354-7
19. Brahos, G.J. and G. Mueller. Late colonic stenosis secondary to seat belt injury. Wis Med J, 1980. 79(2): p. 29-31
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