Ileocecal Valve Endometriosis as a Cause of Acute Intestinal Obstruction

Abstract

Purpose: A 44-year-old woman with a history of gastroesophageal reflux disease treated with pantoprazole and a uterine leiomyoma presented with a one year history of intermittent diffuse abdominal pain which was unrelated to food intake, bowel habits or her menstrual cycle. She recently developed nausea and vomiting but denied any fever, chills, dyspareunia, infertility, dysmenorrhea, diarrhea or obstipation although had no bowel movement for 4 days. Her vital signs were unremarkable and physical examination revealed a mildly distended, non-tender abdomen with hypoactive bowel sounds. A complete blood count and comprehensive metabolic panel was unremarkable. A CT scan of the abdomen and pelvis revealed diffuse ascites, leiomyomatous uterus, mesenteric lymphadenopathy and a high grade partial small bowel obstruction at the terminal ileum likely due to an apple core soft tissue mass. She was managed with intravenous hydration and nasogastric decompression. Ascitic fluid was sampled and the analysis revealed a transudate. Colonoscopy that was performed 4 days later revealed a prominent ileocecal valve with a protruding mass precluding terminal ileal intubation. Biopsies of the suspected mass revealed lymphoid hyperplasia. She subsequently underwent laparoscopic ileocecectomy and pathology revealed multifocal intramural endometriosis with reactive fibrosis. Post-operatively, she had no complications and her symptoms resolved completely without recurrence. Discussion: We report a rare case of a female with no gynecological symptoms in which endometrial infiltration of the ileum and the ileocecal valve caused acute intestinal obstruction, requiring emergency surgery. The gastrointestinal tract is the most common site of extrapelvic endometriosis, with localization to the ileum being rare. It is often confused for malignancy. Establishing a preoperative diagnosis is very difficult in intestinal endometriosis due to the vague abdominal symptoms and normal pathological specimens obtained endoscopically as the lesion rarely invades the mucosa. Conclusion: This entity should be considered in the differential diagnosis of women of child-bearing age who present with symptoms of intestinal obstruction.Figure: [936] Prominent ileocecal valve with a protruding mass.