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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Small bowel obstruction caused by endometriosis in a postmenopausal woman Kunihiko Izuishi,1 Takanori Sano,1 Atsuko Shiota,2,3 Hirohito Mori1 & Kazuo Ebara1 1 Department of Gastroenterological Surgery, Federation of Public Services and Affiliated Personnel Aid Associations, Takamatsu Hospital, Takamatsu, Kagawa, Japan 2 Department of Gynecology, Federation of Public Services and Affiliated Personnel Aid Associations, Takamatsu Hospital, Takamatsu, Kagawa, Japan 3 Department of Nursing, Kagawa Prefectural University of Health Sciences, Takamatsu, Kagawa, Japan
Keywords Postmenopausal women; single-incision laparoscopic surgery; small bowel endometriosis Correspondence Kunihiko Izuishi, Department of Gastroenterological Surgery, Federation of Public Services and Affiliated Personnel Aid Associations, Takamatsu Hospital, 4-18 Tenjinmae, Takamatsu, Kagawa 760-0018, Japan. Tel: +81 87 861 3261 Fax: +81 87 835 0793 Email: [email protected] Received 6 June 2014; revised 28 September 2014; accepted 30 September 2014
Abstract We report a rare case of small bowel obstruction (SBO) caused by endometriosis in a postmenopausal woman. A 54-year-old postmenopausal woman presented with severe abdominal pain and vomiting. Before menopause, she sometimes had abdominal pain associated with menses. Axial multi-dimensional CT images revealed a SBO with small nodules near the terminal ileum. The obstruction was diagnosed as being caused by small bowel endometriosis. Curved planar reconstruction images showed a complicated obstruction of the small intestine 15 cm from the terminal ileum. Based on the stenotic lesion, a SILS procedure was performed. The patient’s SBO diagnosis was histologically confirmed as being caused by small bowel endometriosis. SILS was deemed to be a safe, feasible procedure for treating this bowel obstruction. Curved planar reconstruction images were useful in preoperative imaging and diagnosis of SBO, especially as they were able to highlight the constricting legion.
DOI:10.1111/ases.12154
Introduction Bowel endometriosis occurs in 3%–12% of women with endometriosis, and most cases of bowel endometriosis (85%) are found in the rectum and rectosigmoid junction. Only 7% of all bowel endometriosis cases happen in the small bowel, as occurred in the case presented in this report (1). In most cases, bowel endometriosis does not cause obstruction, and only 1% of cases require surgical intervention (2). Moreover, cases of this disease in postmenopausal women are extremely rare, with only a few reports having described its occurrence in this population (3). SILS has recently gained recognition because of its cosmetic benefit. This technique has been used for various surgical procedures, including cholecystectomy, appendectomy, and colectomy. With regard to small bower obstruction, it has been reported that 10% of patients required conversion to multi-incision laparo-
scopic surgery. Small bowel obstruction (SBO) recurrence was not observed in SILS patients during the median follow-up period of 13.5 months (4). Partial enterectomy for treatment of endometriosis may be performed via SILS, as many affected patients place value on the cosmetic appearance of incision sites. The objective of the present report is to discuss a rare case of SBO caused by small bowel endometriosis in a postmenopausal woman and to describe the use of multidetector row CT (MDCT) for preoperative diagnosis and imaging of small bowel endometriosis.
Case Presentation A 54-year-old woman (para 2) was hospitalized with severe abdominal pain and vomiting 2 years after menopause. Her history included four episodes of ileus during the previous 8 years, all of which were treated by
Asian J Endosc Surg 8 (2015) 205–208 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
205
Small bowel obstruction by endometriosis
K Izuishi et al.
Figure 1 Axial multi-dimensional CT image of small bowel segment with endometriosis. Stricture and small endometriotic nodules are indicated by the white arrow.
conservative therapy (nasogastric tube suctioning). Prior to menopause, she sometimes had abdominal pain associated with menses. The possibility of endometriosis was discussed during these ileus episodes, but further examination was not conducted because the obstruction was rapidly resolved with conservative therapy. The patient had no other past medical history (including hormone replacement therapy) or surgical history. Laboratory diagnostics showed an elevated leukocyte count of 14 100 per mm3 and a serum CA125 level within the normal range. Speculum examination showed that the vagina was moist and not atrophic. Transvaginal ultrasound depicted a thin endometrium and multiple myomas in the uterine body. Axial MDCT images with intravenous contrast medium revealed an SBO with small nodules near the terminal ileum (Figure 1). Curved planar reconstruction (CPR) images showed a complicated stenotic lesion of the small intestine 15 cm from the terminal ileum (Figure 2). Infiltration of small nodules to the other organs was not found. The patient was treated conservatively and recovered after nasointestinal tube decompression. However, during the patient’s 20-day hospitalization, the ileus remitted and relapsed three times. Therefore, a refractory SBO caused by small bowel endometriosis was diagnosed, and SILS was performed using Lapprotector and EZ-Access (Hakko, Nagano, Japan) devices through a 3-cm transumbilical incision. Under detailed observation, a constricting lesion with white endometriotic nodules was found 15 cm from the ileocecal junction (Figure 3), as indicated by preoperative CPR imaging. After exfoliation of adhesions around the obstructed lesion, the small bowel was gently extracted
206
Figure 2 Curved planar reconstruction images. A complicated obstruction of the small intestine was seen 15 cm from terminal ileum. The arrow indicates the stricture, and the dotted arrow indicates the terminal ileum.
Figure 3 Laparoscopic appearance of the small intestine. White lesions mimicking scar tissue were seen.
through the umbilical Lapprotector, and a partial resection of the small bowel with end-to-end anastomosis was performed extracorporeally. The patient’s postoperative course was uneventful and she was discharged 8 days after surgery. Gross appearance of the resected specimen showed small white endometriosis lesions. The small bowel endometriosis caused complicated adhesions due to local fibrosis and it obstructed the small intestine (Figure 4a). Histological examination of the specimen revealed endometriotic glands and stroma from the muscularis propria to the serosal surface in small, fibrotic nodules (Figure 4b). The mucosa was intact, and estrogen
Asian J Endosc Surg 8 (2015) 205–208 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Small bowel obstruction by endometriosis
K Izuishi et al.
Figure 4 (a) Macroscopic appearance of resected specimen. Complicated adhesions and white endometriosis lesions are visible. (b) Histological examination of the specimen. Endometriotic glands and stroma are seen in the small intestine.
receptors, progesterone receptors, and cluster of differentiation 10 were immunohistochemically positive. The patient’s final diagnosis was endometriosis and fibrosis of the small intestine.
Discussion In patients undergoing estrogen hormone replacement therapy, postmenopausal endometriosis can occur due to the presence of synthetic hormones. However, the exact reason for progression of endometriosis in postmenopausal patients without this therapy is not clear. In menopausal women, estrogen may be derived from androgens by the enzyme aromatase, which is stored in adipose tissue and skin (5). Aromatase is also expressed in endometriotic stromal cells. Therefore, endometriotic lesions can convert androgens to estrogen locally due to an abnormal increase in aromatase activity (6). This local production of estrogen is capable of stimulating the growth of endometrial lesions. Another theory posits that interleukins or other inflammatory mediators, rather than estrogen, may stimulate the growth of endometriosis (7).
In the case of large tumors, endometriosis itself can cause intestinal obstruction. Alternatively, with small tumors, the fibrosis resulting from local inflammation can also cause intestinal obstruction through the formation of adhesions (8). Small bowel follow-through is a diagnostic tool commonly used in patients with SBO, but the appearance of small bowel endometriosis is similar to that of Crohn’s disease (9), making an exact diagnosis difficult. In addition, the nodules of small bowel endometriosis usually appear at multiple sites. Therefore, it is important to inspect the whole small intestine during surgery. However, the viewing field during a SILS procedure is restricted due to the movement of instruments, the limited view of the telescope and other instruments, and the loss of instrument triangulation (4). This disadvantage could increase the possibility of overlooking diseased lesions. Thus, an accurate preoperative diagnosis with MDCT imaging is important in order to avoid overlooking possible multiple constricting lesions. Biscaldi et al. reported that MDCT, in combination with colon distension by water enteroclysis, allowed identification of 95% of bowel endometriosis cases (10). In our case, axial images of MDCT taken on admission showed endometriotic lesions near the terminal ileum that were made visible by distention of the surrounding intestines. CPR imaging was also very useful during preoperative planning. These images showed precise information, such as the obstruction location and the extent of the endometriosis. Usually, decompression of the intestines with nasal tubes is necessary for the treatment of SBO, but it is particularly difficult to confirm obstruction sites in the decompressed small intestine during operation. Therefore, the landmark (i.e. 15 cm from the terminal ileum) was important to be sure of the obstruction sites in our case. Preoperative CPR imaging has the advantage of objectively indicating the anatomical site on the basis of radiological examination. However, the most important factor in the diagnosis of this case was the patient’s clinical history of repeated abdominal pain in association with menses. Therefore, the combination of objective MDCT imaging and clinical history was necessary for diagnosis. In conclusion, Crohn’s disease, adhesion after operation, neoplasm, and intussusception are known causes of small bowel stenosis in elderly women. However, bowel endometriosis in postmenopausal women may be on the rise, as the growing frequency of endometriosis parallels the recent trend of late marriage. SILS is indicated for bowel endometriosis because many affected patients value the cosmetic appearance of incision sites. CPR images were useful in preoperative imaging for SILS and diagnosis of small bowel obstruction.
Asian J Endosc Surg 8 (2015) 205–208 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
207
Small bowel obstruction by endometriosis
K Izuishi et al.
cknowledgments The authors have no potential conflicts of interest – financial, professional, or personal – and received no financial support from any company for this study.
References 1. Orbuch IK, Reich H, Orbuch M et al. Laparoscopic treatment of recurrent small bowel obstruction secondary to ileal endometriosis. J Minim Invasive Gynecol 2007; 14: 113–115. 2. de Bree E, Schoretsanitis G, Melissas J et al. Acute intestinal obstruction caused by endometriosis mimicking sigmoid carcinoma. Acta Gastroenterol Belg 1998; 61: 376–368. 3. Popoutchi P, dos Reis Lemos CR, Silva JC et al. Postmenopausal intestinal obstructive endometriosis: Case report and review of the literature. Sao Paulo Med J 2008; 126: 190–193. 4. Liao CH, Liu YY, Chen CC et al. Single-incision laparoscopicassisted surgery for small bowel obstruction. J Laparoendosc Adv Surg Tech A 2012; 22: 957–961.
208
5. Palep-Singh M & Gupta S. Endometriosis: Associations with menopause, hormone replacement therapy and cancer. Menopause Int 2009; 15: 169–174. 6. Utsunomiya H, Cheng YH, Lin Z et al. Upstream stimulatory factor-2 regulates steroidogenic factor-1 expression in endometriosis. Mol Endocrinol 2008; 22: 904–914. 7. Manero MG, Royo P, Olartecoechea B et al. Endometriosis in a postmenopausal woman without previous hormonal therapy: A case report. J Med Case Rep 2009; 3: 135. 8. Slesser AA, Sultan S, Kubba F et al. Acute small bowel obstruction secondary to intestinal endometriosis, an elusive condition: A case report. World J Emerg Surg 2010; 5: 27. 9. Karaman K, Pala EE, Bayol U et al. Endometriosis of the terminal ileum: A diagnostic dilemma. Case Rep Pathol 2012; 2012: 742035. 10. Biscaldi E, Ferrero S, Fulcheri E et al. Multislice CT enteroclysis in the diagnosis of bowel endometriosis. Eur Radiol 2007; 17: 211–219.
Asian J Endosc Surg 8 (2015) 205–208 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Small bowel obstruction caused by endometriosis in a postmenopausal woman Kunihiko Izuishi,1 Takanori Sano,1 Atsuko Shiota,2,3 Hirohito Mori1 & Kazuo Ebara1 1 Department of Gastroenterological Surgery, Federation of Public Services and Affiliated Personnel Aid Associations, Takamatsu Hospital, Takamatsu, Kagawa, Japan 2 Department of Gynecology, Federation of Public Services and Affiliated Personnel Aid Associations, Takamatsu Hospital, Takamatsu, Kagawa, Japan 3 Department of Nursing, Kagawa Prefectural University of Health Sciences, Takamatsu, Kagawa, Japan
Keywords Postmenopausal women; single-incision laparoscopic surgery; small bowel endometriosis Correspondence Kunihiko Izuishi, Department of Gastroenterological Surgery, Federation of Public Services and Affiliated Personnel Aid Associations, Takamatsu Hospital, 4-18 Tenjinmae, Takamatsu, Kagawa 760-0018, Japan. Tel: +81 87 861 3261 Fax: +81 87 835 0793 Email: [email protected] Received 6 June 2014; revised 28 September 2014; accepted 30 September 2014
Abstract We report a rare case of small bowel obstruction (SBO) caused by endometriosis in a postmenopausal woman. A 54-year-old postmenopausal woman presented with severe abdominal pain and vomiting. Before menopause, she sometimes had abdominal pain associated with menses. Axial multi-dimensional CT images revealed a SBO with small nodules near the terminal ileum. The obstruction was diagnosed as being caused by small bowel endometriosis. Curved planar reconstruction images showed a complicated obstruction of the small intestine 15 cm from the terminal ileum. Based on the stenotic lesion, a SILS procedure was performed. The patient’s SBO diagnosis was histologically confirmed as being caused by small bowel endometriosis. SILS was deemed to be a safe, feasible procedure for treating this bowel obstruction. Curved planar reconstruction images were useful in preoperative imaging and diagnosis of SBO, especially as they were able to highlight the constricting legion.
DOI:10.1111/ases.12154
Introduction Bowel endometriosis occurs in 3%–12% of women with endometriosis, and most cases of bowel endometriosis (85%) are found in the rectum and rectosigmoid junction. Only 7% of all bowel endometriosis cases happen in the small bowel, as occurred in the case presented in this report (1). In most cases, bowel endometriosis does not cause obstruction, and only 1% of cases require surgical intervention (2). Moreover, cases of this disease in postmenopausal women are extremely rare, with only a few reports having described its occurrence in this population (3). SILS has recently gained recognition because of its cosmetic benefit. This technique has been used for various surgical procedures, including cholecystectomy, appendectomy, and colectomy. With regard to small bower obstruction, it has been reported that 10% of patients required conversion to multi-incision laparo-
scopic surgery. Small bowel obstruction (SBO) recurrence was not observed in SILS patients during the median follow-up period of 13.5 months (4). Partial enterectomy for treatment of endometriosis may be performed via SILS, as many affected patients place value on the cosmetic appearance of incision sites. The objective of the present report is to discuss a rare case of SBO caused by small bowel endometriosis in a postmenopausal woman and to describe the use of multidetector row CT (MDCT) for preoperative diagnosis and imaging of small bowel endometriosis.
Case Presentation A 54-year-old woman (para 2) was hospitalized with severe abdominal pain and vomiting 2 years after menopause. Her history included four episodes of ileus during the previous 8 years, all of which were treated by
Asian J Endosc Surg 8 (2015) 205–208 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
205
Small bowel obstruction by endometriosis
K Izuishi et al.
Figure 1 Axial multi-dimensional CT image of small bowel segment with endometriosis. Stricture and small endometriotic nodules are indicated by the white arrow.
conservative therapy (nasogastric tube suctioning). Prior to menopause, she sometimes had abdominal pain associated with menses. The possibility of endometriosis was discussed during these ileus episodes, but further examination was not conducted because the obstruction was rapidly resolved with conservative therapy. The patient had no other past medical history (including hormone replacement therapy) or surgical history. Laboratory diagnostics showed an elevated leukocyte count of 14 100 per mm3 and a serum CA125 level within the normal range. Speculum examination showed that the vagina was moist and not atrophic. Transvaginal ultrasound depicted a thin endometrium and multiple myomas in the uterine body. Axial MDCT images with intravenous contrast medium revealed an SBO with small nodules near the terminal ileum (Figure 1). Curved planar reconstruction (CPR) images showed a complicated stenotic lesion of the small intestine 15 cm from the terminal ileum (Figure 2). Infiltration of small nodules to the other organs was not found. The patient was treated conservatively and recovered after nasointestinal tube decompression. However, during the patient’s 20-day hospitalization, the ileus remitted and relapsed three times. Therefore, a refractory SBO caused by small bowel endometriosis was diagnosed, and SILS was performed using Lapprotector and EZ-Access (Hakko, Nagano, Japan) devices through a 3-cm transumbilical incision. Under detailed observation, a constricting lesion with white endometriotic nodules was found 15 cm from the ileocecal junction (Figure 3), as indicated by preoperative CPR imaging. After exfoliation of adhesions around the obstructed lesion, the small bowel was gently extracted
206
Figure 2 Curved planar reconstruction images. A complicated obstruction of the small intestine was seen 15 cm from terminal ileum. The arrow indicates the stricture, and the dotted arrow indicates the terminal ileum.
Figure 3 Laparoscopic appearance of the small intestine. White lesions mimicking scar tissue were seen.
through the umbilical Lapprotector, and a partial resection of the small bowel with end-to-end anastomosis was performed extracorporeally. The patient’s postoperative course was uneventful and she was discharged 8 days after surgery. Gross appearance of the resected specimen showed small white endometriosis lesions. The small bowel endometriosis caused complicated adhesions due to local fibrosis and it obstructed the small intestine (Figure 4a). Histological examination of the specimen revealed endometriotic glands and stroma from the muscularis propria to the serosal surface in small, fibrotic nodules (Figure 4b). The mucosa was intact, and estrogen
Asian J Endosc Surg 8 (2015) 205–208 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Small bowel obstruction by endometriosis
K Izuishi et al.
Figure 4 (a) Macroscopic appearance of resected specimen. Complicated adhesions and white endometriosis lesions are visible. (b) Histological examination of the specimen. Endometriotic glands and stroma are seen in the small intestine.
receptors, progesterone receptors, and cluster of differentiation 10 were immunohistochemically positive. The patient’s final diagnosis was endometriosis and fibrosis of the small intestine.
Discussion In patients undergoing estrogen hormone replacement therapy, postmenopausal endometriosis can occur due to the presence of synthetic hormones. However, the exact reason for progression of endometriosis in postmenopausal patients without this therapy is not clear. In menopausal women, estrogen may be derived from androgens by the enzyme aromatase, which is stored in adipose tissue and skin (5). Aromatase is also expressed in endometriotic stromal cells. Therefore, endometriotic lesions can convert androgens to estrogen locally due to an abnormal increase in aromatase activity (6). This local production of estrogen is capable of stimulating the growth of endometrial lesions. Another theory posits that interleukins or other inflammatory mediators, rather than estrogen, may stimulate the growth of endometriosis (7).
In the case of large tumors, endometriosis itself can cause intestinal obstruction. Alternatively, with small tumors, the fibrosis resulting from local inflammation can also cause intestinal obstruction through the formation of adhesions (8). Small bowel follow-through is a diagnostic tool commonly used in patients with SBO, but the appearance of small bowel endometriosis is similar to that of Crohn’s disease (9), making an exact diagnosis difficult. In addition, the nodules of small bowel endometriosis usually appear at multiple sites. Therefore, it is important to inspect the whole small intestine during surgery. However, the viewing field during a SILS procedure is restricted due to the movement of instruments, the limited view of the telescope and other instruments, and the loss of instrument triangulation (4). This disadvantage could increase the possibility of overlooking diseased lesions. Thus, an accurate preoperative diagnosis with MDCT imaging is important in order to avoid overlooking possible multiple constricting lesions. Biscaldi et al. reported that MDCT, in combination with colon distension by water enteroclysis, allowed identification of 95% of bowel endometriosis cases (10). In our case, axial images of MDCT taken on admission showed endometriotic lesions near the terminal ileum that were made visible by distention of the surrounding intestines. CPR imaging was also very useful during preoperative planning. These images showed precise information, such as the obstruction location and the extent of the endometriosis. Usually, decompression of the intestines with nasal tubes is necessary for the treatment of SBO, but it is particularly difficult to confirm obstruction sites in the decompressed small intestine during operation. Therefore, the landmark (i.e. 15 cm from the terminal ileum) was important to be sure of the obstruction sites in our case. Preoperative CPR imaging has the advantage of objectively indicating the anatomical site on the basis of radiological examination. However, the most important factor in the diagnosis of this case was the patient’s clinical history of repeated abdominal pain in association with menses. Therefore, the combination of objective MDCT imaging and clinical history was necessary for diagnosis. In conclusion, Crohn’s disease, adhesion after operation, neoplasm, and intussusception are known causes of small bowel stenosis in elderly women. However, bowel endometriosis in postmenopausal women may be on the rise, as the growing frequency of endometriosis parallels the recent trend of late marriage. SILS is indicated for bowel endometriosis because many affected patients value the cosmetic appearance of incision sites. CPR images were useful in preoperative imaging for SILS and diagnosis of small bowel obstruction.
Asian J Endosc Surg 8 (2015) 205–208 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
207
Small bowel obstruction by endometriosis
K Izuishi et al.
cknowledgments The authors have no potential conflicts of interest – financial, professional, or personal – and received no financial support from any company for this study.
References 1. Orbuch IK, Reich H, Orbuch M et al. Laparoscopic treatment of recurrent small bowel obstruction secondary to ileal endometriosis. J Minim Invasive Gynecol 2007; 14: 113–115. 2. de Bree E, Schoretsanitis G, Melissas J et al. Acute intestinal obstruction caused by endometriosis mimicking sigmoid carcinoma. Acta Gastroenterol Belg 1998; 61: 376–368. 3. Popoutchi P, dos Reis Lemos CR, Silva JC et al. Postmenopausal intestinal obstructive endometriosis: Case report and review of the literature. Sao Paulo Med J 2008; 126: 190–193. 4. Liao CH, Liu YY, Chen CC et al. Single-incision laparoscopicassisted surgery for small bowel obstruction. J Laparoendosc Adv Surg Tech A 2012; 22: 957–961.
208
5. Palep-Singh M & Gupta S. Endometriosis: Associations with menopause, hormone replacement therapy and cancer. Menopause Int 2009; 15: 169–174. 6. Utsunomiya H, Cheng YH, Lin Z et al. Upstream stimulatory factor-2 regulates steroidogenic factor-1 expression in endometriosis. Mol Endocrinol 2008; 22: 904–914. 7. Manero MG, Royo P, Olartecoechea B et al. Endometriosis in a postmenopausal woman without previous hormonal therapy: A case report. J Med Case Rep 2009; 3: 135. 8. Slesser AA, Sultan S, Kubba F et al. Acute small bowel obstruction secondary to intestinal endometriosis, an elusive condition: A case report. World J Emerg Surg 2010; 5: 27. 9. Karaman K, Pala EE, Bayol U et al. Endometriosis of the terminal ileum: A diagnostic dilemma. Case Rep Pathol 2012; 2012: 742035. 10. Biscaldi E, Ferrero S, Fulcheri E et al. Multislice CT enteroclysis in the diagnosis of bowel endometriosis. Eur Radiol 2007; 17: 211–219.
Asian J Endosc Surg 8 (2015) 205–208 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
