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Meredith Dixon
6 years ago
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1 «æ å μ Ù-ı ªï Ë Ú Ë ÚııÛ Reg 4-5 Med J Vol. 29 No. 1 January - March 2010 ß πºÿâªé«a Case Report Sigmoid Endometriosis Mimicking Carcinoma of Sigmoid Colon : A Case Report ª æ ß» Ï æ» æ., Prasopchai Kongsakphaisal M.D., «.«.»» μ å Ë«ª Thai Board of General Surgery ÿà ß π» Division of Surgery ßæ π ª Nakhonpathom Hospital ABSTRACT Although intestinal endometriosis is not uncommon in women of reproductive age. Endometriosis of colon that involved mucosa is quite rare and differential diagnosis from colon cancer may be difficult. We present a case of middle-age woman with colonic endometriosis. Her initial clinical diagnosis including radiologic and endoscopic studies was sigmoid colon cancer with right ureteric involvement. After laparotomy and en-bloc resection, the histological examination revealed extensive involvement of endometriosis. Conclusion : Colonic endometriosis is a relatively rare disease and is difficult to differentiate from malignancy. Keywords : Colonic endometriosis, intestinal endometriosis, mimicking colon cancer àõ â«à «ËÕ ÿ Ÿ Èπº Ë Ë π â æ â â ß πºÿâà ß«æ π ÿå μà «ËÕ ÿ Ÿ Èπº Ë Ë π ËÕ ÿºπ ß â À à â π π àõπ â ßæ âπâõ «π â «Áß π â À à ß ππ È Õ πõ ß πºÿâªé«à ß «ß π ªìπ «ËÕ ÿ Ÿ Èπº Ë Ë â À à Ëß «π μõπ Õ μ «à ß æ ß ß àõß âõß â À à «à ªìπ Áß â À à Ë ª àõ μ «À ß ºà μ â«º μ «Èπ π ÈÕæ «à ªìπ ËÕ ÿ Ÿ Èπº Ë ÿª : «ËÕ ÿ Ÿ Èπº Ë π â À àæ â àõπ â ßπâÕ «π â «Áß π â À à

2 «æ å μ 4-5 ªï Ë 29 Ë 1 - π We described the case of 41 years old woman who had presented with recurrent abdominal pain for 2 years. She also had complaint about bowel habit change, mucous bloody stool and was treated as infectious diarrhea with antibiotics and analgesic drugs for many times. She had maliase, loss of appetite and 5 kg of weight in last 4 months. A month before attending surgery, she was admitted because of severe diarrhea. About the past history, she was diagnosed myoma uteri and transabdominal hysterectomy was done at 18 years ago. There was no familial history of colon cancer or endometriosis. There was also no history of bleeding tendency. Other systemic review was negative. On physical examination she was not pale, afebrile, no edema and normal mentation. The head, neck and chest were unremarkable. Abdominal examination revealed normal gurgling sound with no mass, distention or tenderness. Per rectal examination disclosed normal mucosa and sphincter tone, no lesion but mucous bloody stool was noted. The blood tests revealed normal level of CBC, FBS, BUN, CT, eletrolytes and CEA. Urine examination was also in normal limit. Barium enema was sent and revealed a persistent narrowing of sigmoid colon with irregular outline and overhanging edges, measuring about 2 cm in length. Only small amount of barium contrast could pass into proximal sigmoid colon. Impression of radiologist was sigmoid colon cancer caused partial colonic obstruction. colonoscope could not pass to proximal part of colon. Multiple biopsies were performed. Pathologist reported non-active chronic colitis with no evidence of malignancy. So CT colonoscopy was requested for staging and searching for synchronous lesion. CT colonoscopy revealed eccentric intraluminal mass at distal sigmoid colon extended to extracolon about 4.2 x 5.7 x 5.5 cm causing nearly complete obliteration of affected sigmoid lumen. The mass encased right distal ureter about cm long with moderate hydroureteronephrosis and invaded right ovary and few pericolonic nodes. No demonstrate colonic polyp and metastasis disease. All of those findings except pathological report suggested that she had sigmoid cancer with invasion of right ureter, right ovary and few regional nodes (T4N1Mx). After discussion with patient, she decided to undergo surgery. So urologist was consulted for Colonoscopy was performed and demonstrated stricture of rectosigmoid colon at 15 cm from anal verge without definite mass or ulceration. The Fig. 1 Barium enema : narrowing of sigmoid colon with irregular outline and overhanging edges, measuring about 2 cm in length

3 Region 4-5 Medical Journal Vol. 29 No. 1 January-March Sigmoid Endometriosis Mimicking Carcinoma of Sigmoid Colon : A Case Report Fig. 2 CT abdomen showed distal sigmoid colon mass with encasement of right ureter A. axial view B. coronal view C. sagittal view pre operative double-j ureteric stenting. Plan of surgery was anterior rectosigmoid colonic en-bloc resection with right ureter and right ovary. Laparotomy was done through midline vertical incision and revealed mass at rectosigmoid colon sized about 5 cm invading through serosa of colon Fig. 3 CT colonoscopy showed intraluminal mass with nearly obstruction of colonic lumen

4 «æ å μ 4-5 ªï Ë 29 Ë 1 - π Fig. 4 Gross specimen : en-bloc resection of sigmoid colon, right ureter and right ovary and adhering with right ureter and right ovary causing right hydroureteronephrosis. So anterior en bloc resection of rectosigmoid and right ureter and ovary was performed. Colorectal anastomosis was done by circular staple and uretero-ureterostomy anastomosis was performed with double-j stent without tension. Histological examination revealed extensively involved by endometriosis with marked tissue fibrosis, including sigmoid colon, vaginal wall, right ovary Fig. 5 Mucosal involvement of distal sigmoid colon mass and 2 lymph nodes. The right ureter and fallopian tube showed unremarkable change.

5 Region 4-5 Medical Journal Vol. 29 No. 1 January-March Sigmoid Endometriosis Mimicking Carcinoma of Sigmoid Colon : A Case Report Discussion Endometriosis is an estrogen-dependent inflammatory disease that affects 5 to 10% of women of reproductive age. 1 Its defining feature is the presence of endometrium-like tissue outside the uterine cavity. Endometriotic implants are most commonly found in the pelvis in decreasing order of frequency on the ovaries, the posterior broad ligament, the anterior cul-de-sac, the posterior cul-de-sac, the uterosacral ligaments and the anterior wall of the rectosigmoid colon. 2 Among the extrapelvic endometriosis, gastrointestinal tract is the most common site and rectosigmoid is the most common involved areas (75-90%). Other parts of the bowel commonly affected are the distal ileum (2-16%) and appendix (3-18%). 3 Although the incidence of colorectal involvement in women with endometriosis is quite high, severe involvement necessitates bowel resection is < 10%. 4 Case reports of colonic endometriosis mimicking adenocarcinoma of colon are scattered throughout the literature describing this phenomenon. 5-8 Most of symptoms are abdominal crampy pain, rectal or pelvic pain, cyclical rectal bleeding, tenesmus, constipation (especially with menses), decreased stool caliber, bloating, nausea, vomiting, diarrhea. 2 These clinical manifestations are sometimes difficult to distinguish from malignancy. The cyclic nature of the symptoms with exacerbations just before or during menstruation yields a clue to the diagnosis but there are in only approximated 40% of patients. 5 Radiologic and endoscopic examinations are essential for the diagnosis of intestinal endometriosis, which may be confused with malignancy, based on colonoscopy and CT scan, particularly in patients with mucosal involvement. The diagnosis is quite difficult even in endoscopic biopsy because mucosal involvement is often focally. So until now the gold standard diagnostic procedure for intestinal endometriosis is laparoscopy or laparotomy. Recently, there have been reports of successful laparoscopic management of endometriosis, even when bowel resection is indicated. 9 However, laparoscopic surgery for severe bowel endometriosis is more difficult and requires a more advanced technique. Endocrine treatment alone has proved ineffective in patients with intestinal endometriosis that produces symptoms. The only successful mode of treatment for gastrointestinal endometriosis that prevents subsequent recurrence is resection of the affected segment and a total abdominal hysterectomy and bilateral salpingo-oophorectomy except the patient still desires to have a family. 2 The preoperative diagnosis of severe ureteral and rectal wall involvement would aid in surgical treatment. Preoperative placement of ureteric stent is very helpful for severe ureteral involvement. The medications used for the treatment of endometriosis are danazol, high dose progestins and GnRH agonists with almost equivalent efficacy. The choice of which to use is based on side effects and costs. 10 We report a case of rectosigmoid endometriosis that preoperative misdiagnosed as rectosigmoid colon cancer. The symptoms of bowel habit change, abdominal pain, mucous bloody stool in combination with colonoscopic and radiologic findings were suggestive of malignancy although the colonoscopic biopsies were not confirmative. These were

6 «æ å μ 4-5 ªï Ë 29 Ë 1 - π indication for resection. We performed en-bloc resection (anterior resection, right ureterectomy with endto-end anastomosis and oophorectomy) for the diagnosis we had made. Subsequent pathological study of surgical specimens revealed intestinal endometriosis. In conclusion, colonic endometriosis is often a diagnostic challenge mimicking colonic cancer when based on clinical symptoms, endoscopic procedure and radiologic findings. In reproductive female patients who have unexplained digestive complaints, endometriosis should also be considered in the differential diagnosis. References 1. Bulun SE. Endometriosis. N Engl J Med 2009 ; 360 : Gordon PH. Miscellaneous Entities. In : Gordon PH, Nivatvongs S, editors. Principles and practice of surgery for the colon, rectum and anus. 3 rd ed. New York : Informal healthcare USA ; 2007 : Dimoulios P, Koutroubakis IE, Tzardi M, Antoniou P, Matalliotakis IM, Kouroumalis EA. A case of sigmoid endometriosis difficult to differentiate from colon cancer. BMC Gastroenterol 2003 ; 3 : Bailey HR. Colorectal endometriosis. Perspect Colon Rectal Surg 1992 ; 5 : Akbar M, Tasleem SH, Ahmed N, Casillas GL, Ford JG. Colonic endometriosis mimicking colon cancer. Gastroenterology & Hepatology 2009 ; 5 : Alhumidi AA, Hamodat MM. Colonic endometriosis mimicking colonic carcinoma. The Internet Journal of Pathology 2009 ; 8 :(2). 7. Kim JS, Hur H, Min BS, Kim H, Sohn S, Cho CH, Kim NK, et al. Intestinal Endometriosis Mimicking Carcinoma of Rectum and Sigmoid Colon : A Report of Five Cases. Yonsei Med J 2009 ; 50 : Samet JD, Horton KM, Fishman EK, Hruban RH. Colonic Endometriosis Mimicking Colon Cancer on a Virtual Colonoscopy Study : A Potential Pitfall in Diagnosis. Case Reports in Medicine 2009 ; 8 : Duepree HJ, Senagore AJ, Delaney CP, Marcello PW, Brady KM, Falcone T. Laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement. J Am Coll Surg 2002 ; 195 : Snyder MJ, Stryker SJ. Endometriosis. In : Wolff BG, Fleshman JW, Beck DE, Pemberton JH, Wexner SD. The ASCRS Textbook of Colon and Rectal Surgery. New York, NY : Springer ; 2006 :

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