SignificanceEndometriosis affects 10% of females within reproductive age. The intestine is affected in 3% of those with ectopic endometriosis, and the terminal ileum is rarely affected. The most common presentation is bleeding and seldom presents as acute bowel obstruction.Clinical PresentationThe patient is a 39-year-old female who complained of bloating, vomiting of previously ingested food, diarrhea, and generalized abdominal pain. Colonoscopy and transvaginal ultrasound were normal. Abdominal imaging revealed ileus and ileal wall thickening.ManagementPatient was sent for laparotomy, where the terminal ileum was resected. Biopsy revealed endometrial tissue.ConclusionPreoperative diagnosis of intestinal endometriosis is difficult due to its rarity and vagueness of symptoms. The diagnosis is based on a high index of suspicion. We recommended that intestinal endometriosis be included in the differential diagnosis in a female patient of reproductive age presenting with colicky abdominal pain or intestinal obstruction. SignificanceEndometriosis affects 10% of females within reproductive age. The intestine is affected in 3% of those with ectopic endometriosis, and the terminal ileum is rarely affected. The most common presentation is bleeding and seldom presents as acute bowel obstruction. Endometriosis affects 10% of females within reproductive age. The intestine is affected in 3% of those with ectopic endometriosis, and the terminal ileum is rarely affected. The most common presentation is bleeding and seldom presents as acute bowel obstruction. Clinical PresentationThe patient is a 39-year-old female who complained of bloating, vomiting of previously ingested food, diarrhea, and generalized abdominal pain. Colonoscopy and transvaginal ultrasound were normal. Abdominal imaging revealed ileus and ileal wall thickening. The patient is a 39-year-old female who complained of bloating, vomiting of previously ingested food, diarrhea, and generalized abdominal pain. Colonoscopy and transvaginal ultrasound were normal. Abdominal imaging revealed ileus and ileal wall thickening. ManagementPatient was sent for laparotomy, where the terminal ileum was resected. Biopsy revealed endometrial tissue. Patient was sent for laparotomy, where the terminal ileum was resected. Biopsy revealed endometrial tissue. ConclusionPreoperative diagnosis of intestinal endometriosis is difficult due to its rarity and vagueness of symptoms. The diagnosis is based on a high index of suspicion. We recommended that intestinal endometriosis be included in the differential diagnosis in a female patient of reproductive age presenting with colicky abdominal pain or intestinal obstruction. Preoperative diagnosis of intestinal endometriosis is difficult due to its rarity and vagueness of symptoms. The diagnosis is based on a high index of suspicion. We recommended that intestinal endometriosis be included in the differential diagnosis in a female patient of reproductive age presenting with colicky abdominal pain or intestinal obstruction.