Acute Bowel Obstruction Due to Endometriosis Treated With Colonic Stent

Abstract

Introduction: Endometriosis is defined as the presence of extrauterine endometrium. It affects up to 8% of premenopausal women. Intestinal involvement is the most common extrapelvic site, affecting 5.4% of women with endometriosis, and out of which rectosigmoid endometriosis comprises 90%. Endometriosis is an extremely rare cause of large bowel obstruction. Urgent surgical intervention carries high morbidity and mortality, and operative intervention can be more difficult in extensive pelvic endometriosis. Less invasive alternatives can be considered in this situation. Case Report: A 35-year-old female presented with 2 weeks of progressive abdominal pain, nausea, and constipation. She denied hematochezia and reported no other gastrointestinal problem. She was afebrile, hemodynamically stable, and in moderate distress due to abdominal pain. Abdomen was diffusely tender, distended, and bowel sounds were present. Rectal exam revealed no abnormality. WBC count was 15 K. CT abdomen showed distended large bowel and colonic obstruction due to distal sigmoid colon stricture. A discrete mass was not seen. Colonoscopy showed tight colonic stricture with sharp angle at 18 cm above dentate line, unable to pass endoscope. The edge of the stricture was biopsied. A guide wire was advanced into the dilated colon proximal to stricture. Contrast injection revealed a 2.5-cm-long stricture. A 2.5-cm x 8-cm uncovered stent was deployed after consulting with the surgical team. Pathology showed benign edematous colonic mucosa. She did well for 2 days with scant semi-formed stools, but her symptoms got worse, and she ultimately underwent surgery. Upon initial inspection of bowel during surgery, the cecum and sigmoid colon were very dilated. The cecum was ischemic in appearance with splitting of the serosa in several areas. There was a hard, obstructing lesion in the proximal rectum, just distal to the confluence of tenia. The proximal sigmoid was resected. The initial surgical impression was diverticular disease, but pathology revealed extensive sigmoid colon endometriosis. Discussion: It is very rare to have endometriosis leading to bowel obstruction without any prior symptoms or history of endometriosis. This is the second reported case of acute bowel obstruction treated initially with colonic stent. Colonic stenting is currently widely used in malignant obstruction. The use of self expanding metallic stents to treat benign conditions is controversial; however, due to associated long-term complications. This case demonstrates that stenting can provide a bridge to major surgery in the rare event of acute endometriotic colonic obstruction. The initial treatment with stent can provide time to prepare and medically optimize the patient for surgery.