Chronic Abdominal Pain and Bleeding in a Post Hysterectomy Female

Abstract

1) To recognize endometriosis as an important diagnosis in a post hysterectomy female with chronic abdominal pain 2) To illustrate that inadequate performance, biopsy and evaluation of colonic lesions may miss a diagnosis of endometriosis. Case Information: We report a rare case of a 47 year old woman with severe chronic abdominal pain complicated by 8 months of rectal bleeding. Her only pertinent medical history is that of a partial hysterectomy for uterine fibroids at age 30. Initial evaluation by colonoscopy at an outside hospital revealed a friable mass 25 cm from the anal verge with a negative biopsy. Repeat colonoscopy following a new partial small bowel obstruction revealed a sigmoid mass with an additional negative biopsy. This patient was subsequently referred to our medical center for evaluation. Physical exam revealed a midline abdominal scar with diffuse lower abdominal pain. Her pelvic exam was normal and rectal exam demonstrated heme positive brown stool. Hemoglobin, electrolytes, and iron studies were all normal. CT scan of the abdomen and pelvis revealed prior hysterectomy with no mass lesions. A colonoscopy using a pediatric colonoscope demonstrated a narrowing in the sigmoid colon. A 3cm soft mucosal lesion was seen at 30cm from anal verge. The mucosa was friable and edematous. Multiple large biopsies revealed mucosal involvement of endometriosis and a special stain was positive for CK7 and CD10, both of which are specific to uterine stroma. In consultation with the Gynecology service, this patient was started on leuprolide and all of her symptoms completely resolved. Discussion: The gastrointestinal tract is the next most common site for endometriosis after the reproductive organs and pelvic peritoneum. The overall prevalence of gastrointestinal endometriosis is 3–24% of cases. The population prevalence of symptomatic bowel endometriosis is only 2%. Thus far, mucosal involvement with bleeding has been reported in few cases. This patient developed a complicated course with bowel obstruction and severe abdominal pain. Diagnosis was postponed for an extended period of time. Only colonoscopic examination and multiple biopsies with special staining revealed endometriosis. Diagnosis requires a thorough history and physical, careful endoscopy with adequate biopsy, and strict review by a pathologist. Early diagnosis can significantly improve quality of life in women with endometriosis.