Not Just Another Case of Small Intestinal Obstruction

Abstract

Introduction: Small bowel obstruction is a common cause of hospitalization. The more common causes for mechanical intestinal obstruction are post-operative adhesions, hernias and tumors. In non complicated patients, a reasonable time before considering surgery is between 2-5 days with close monitoring of the patient. We present an atypical case of a woman who presented with small bowel obstruction. Case Presentation: 46 y/o woman is admitted after two previous visits to other institutions. She presented with nausea, vomiting, some diarrhea, and abdominal distension associated to a 35-pound weight loss. Onset of symptoms was 6 months prior to our admission. Extensive review of previous admissions, including upper endoscopy, colonoscopies and radiologic studies was accomplished. Physical exam of patient was significant for exquisite pain and tenderness of superficial and deep palpation of the epigastric area of abdomen associated to remarkable abdominal distention and rushes. Oral mucosa was dry with poor turgor of the skin. Rest of the physical exam was unremarkable. Laboratory findings of a previous visit to ER were completely normal with Hgb of 13.9, Hct of 41.3 and platelets of 358. Patient also had a normal CBC and diff with absolutely no electrolyte disturbances, amylase 40 U/L and lipase 24 U/L. EKG showed tachycardic but regular rhythm, no axis deviation, no ST changes. Abdominopelvic-CT scan with intravenous contrast suggested partial small bowel obstruction without lymphadenopathy. No masses were identified. During admission patient was placed on nasogastric tube suction, I.V. fluids and antibiotics. Given persistence of symptoms she underwent exploratory laparotomy. A mass involving the ileum and cecum was found. Hemicolectomy with segmental small bowel resection was performed. Immediate post-operative course was uneventful and after three days in the ICU, patient was transferred to general ward. Mass pathology was reported as endometrioma. Patient was discharged home six days after admission. Discussion: Ileo-cecal endometrioma as the cause for small bowel obstruction is a rare occurrence. It presents a real challenge to the clinician itself. Depending on the level of obstruction, it can present with a series of non-specific symptoms such as abdominal pain, distension, fecal vomiting, weight loss and constipation. This patient presented with weight loss, abdominal pain and significant abdominal distention. Although clinical dehydration was a key element for admission, she was never complicated by electrolyte abnormalities, respiratory issues or bowel ischemia. We need to consider the possibility of endometriosis, as the cause of small bowel obstruction in any childbearing age female.