Expect the Unexpected in a Colonoscopy: A Case of Colonic Endometriosis

Abstract

Endometriosis is defined by the presence and the proliferation of endometrial tissue outside the uterus. Estimate prevalence is nearly 10-15% in women of reproductive age group. Symptoms vary according to location where endometrial tissue is implanted. Intestinal endometriosis can occur in up to 37% of all cases of endometriosis, mainly affecting recto sigmoid part of colon. Our patient is a 32-year-old female with past history of infantile cerebral palsy, seizure disorder and chronic constipation presented to our gastroenterology clinic with abdominal pain. Symptoms have been waxing and waning for years, described as diffuse abdominal pain, cramping in nature and associated with severe constipation. Patient denied any other symptoms, including hematemesis, hematochezia or melena. Patient reported family history of unknown cancer. Physical exam was remarkable for scars from previous cesarean sections. No abdominal tenderness, guarding or rigidity was appreciated. Basic laboratory testing was unremarkable. Colonoscopy visualized a 1 cm sessile polyp (figure 1) in descending colon that was snared, cauterized and retrieved (figure 2). Histology of the polyp revealed benign endometrial glands and stroma, consistent with diagnosis of endometriosis. Patient was started on oral contraceptive medication with dramatic improvement of abdominal pain before patient preferentially stopped it due to weight gain. A follow up colonoscopy for recurrent abdominal pain visualized diminutive polyp in the sigmoid colon that was removed by snare polypectomy. Pathology was consistent with hyperplastic polyp. On outpatient follow up, patient denied any more symptoms of abdominal pain. Endometriosis is a hormone responsive pathological implanting of endometrial tissue outside the uterus. Symptoms of endometriosis vary. Intestinal endometriosis usually manifests as alteration in bowel habits, rectal bleeding and dyschezia. Our patient presented with non-specific abdominal pain that initially responded with oral contraceptive medication. Although patient with diagnosis of endometriosis usually tend to be infertile unless treated, our patient had delivered more than once before she was diagnosed with endometriosis. We present this case so we as gastroenterologist and internists would have low index of suspecion of this rare pathology.Figure: Colonoscopy visualized a 1 cm sessile polyp in the descending colon.Figure: Appearance of bleeding polyp after it was snared and cautarized.