Co-existent Crohnʼs Disease and Endometriosis on Initial Presentation in A Young Female with Small bowel Obstruction

Abstract

Purpose: In young patients Crohn's Disease can present initially as small bowel obstruction. Small bowel endometriosis is also known to present with obstruction. We report a case of a patient with small bowel obstruction who was found to have active Crohn's disease and endometriosis. Methods: A 25 year old female with no past history presented with severe abdominal pain, nausea and vomiting for 4 days. The patient was thin and toxic appearing. Physical examination revealed abdominal distension, diffuse tenderness and absent bowel sounds. Results: Labs showed a hemoglobin of 10.9 g/dl and a C-reactive protein of 5mg/dl. Pregnancy test was negative. Abdominal CT scan showed a dilated small bowel, with the distal small bowel significantly thickened. The terminal ileum demonstrated a transition zone with under distension. The patient was initially treated conservatively however she continued to have severe abdominal pain and obstipation so she was taken to surgery. Laparotomy demonstrated an inflamed terminal ileum with a mass like appearance and adhesions. The rest of the small and large bowel appeared normal. Histologic examination of the ileocolic resection showed islands of endometrial tissue in the muscularis propria consistent with endometriosis and serpingenous deep mucosal ulceration with “cobblestone” appearance characteristic of Crohn's disease. The appendix and ileo-cecal valve were also involved without dysplasia. Conclusion: Gastrointestinal involvement is found in 3%-37% of women with endometriosis. The rectosigmoid, appendix, and terminal ileum are most frequently affected. Exclusive localization to the ileum is very rare. Endometriosis of the distal ileum is an infrequent cause of intestinal obstruction, ranging from 7%-23% of all cases with intestinal involvement. When the terminal ileum is affected, endometriosis can simulate Crohn's disease both clinically and radiologically. In our case however both conditions were diagnosed at the initial presentation. A more common presentation is endometriosis complicating known Crohn's disease. The similarities between the presentations of the two conditions make it difficult to distinguish which entity was causing the patient's symptoms. This is important as the prognosis and treatment of the two differ. Our patient gradually improved after her surgery. She was doing well at follow-up one month later.