A Case of Endometriosis Causing Colonic Inertia

Abstract

Introduction: Endometriosis is a frequently missed diagnosis especially when it primarily manifests as a gastrointestinal disorder. The exact prevalence of intestinal endometriosis is unknown. This case illustrates three important principles involving intestinal endometriosis besides awareness; (1) the need to consider the diagnosis in women, especially of childbearing age, presenting with non-specific abdominal complaints such as constipation, diarrhea, and recurrent abdominal pain; (2) the need for more studies focusing on the true prevalence and management of the disease; (3) the possible role of EUS in the diagnosis. Case: A 35-year-old female patient with no other significant medical or surgical history presented to her colorectal surgeon with worsening chronic constipation over the past two years despite maximal medical management with fluid intake, fiber supplementation, and laxative and enema use. Previous CT of abdomen and pelvis was unremarkable. Colonoscopy was significant for a large amount of retained stool despite adequate intake of preparation. A colonic transit study demonstrated severely delayed colonic transit. Anal defecography was unremarkable. After careful discussion with the patient and recommendation for referral to an advanced motility center, the patient elected for surgical management with total abdominal colectomy with ileorectal anastomosis. Pathology revealed significant endometriosis of the colon involving subserosa and muscularis propria. Upon retrospective questioning, patient admitted to having gynecologic complaints, i.e. dyspareunia. Significant depression, failure to thrive, and a surgical wall abscess complicated her postoperative course. Discussion: Intestinal endometriosis is likely a diagnosis that is frequently overlooked. The prevalence of the disease is truly unknown. Although surgical management is the mainstay therapy of the disease, there are no large, prospective studies to compare medical to surgical outcomes. Therefore, more studies are needed to understand the nature and management of this disease especially to determine if patients can be spared from morbid surgeries. Finally, EUS theoretically may have a role in the diagnosis of the disease. One prospective study showed that the performance of rectal EUS was similar to transvaginal US in diagnosis of rectal vaginal endometriosis.