Small Bowel Obstruction Caused by Ileal Endometriosis with Appendiceal and Lymph Node Involvement Treated with Single-Incision Laparoscopic Surgery: A Case Report and Review of the Literature

Digestive system deep infiltrating endometriosis: What do we know

Digestive system infiltrating endometriosis (DSIE) is an uncommon form of endometriosis in the digestive system. DSIE often occurs in the intestines (especially the sigmoid rectum), liver, gallbladder and pancreas. Clinically, DSIE presents with the same symptoms as endometriosis, including cyclic pain, bleeding and infertility, in addition to specific biliary/intestinal obstruction and gastrointestinal bleeding. Compared to general endometriosis, DSIE has unique biological behaviour and pathophysiological mechanisms. Most DSIEs are deep invasive endometrioses, characterized by metastasis to the lymph nodes and lymphatic vessels, angiogenesis, peripheral nerve recruitment, fibrosis and invasion of surrounding tissues. DSIE-related peripheral angiogenesis is divided into three patterns: angiogenesis, vasculogenesis and inosculation. These patterns are regulated by interactions between multiple hypoxia-hormone cytokines. The nerve growth factors regulate the extensive neurofibril recruitment in DSIE lesions, which accounts for severe symptoms of deep pain. They are also associated with fibrosis and the aggressiveness of DSIE. Cyclic changes in DSIE lesions, recurrent inflammation and oxidative stress promote repeated tissue injury and repair (ReTIAR) mechanisms in the lesions, accelerating fibril formation and cancer-related mutations. Similar to malignant tumours, DSIE can also exhibit aggressiveness derived from collective cell migration mediated by E-cadherin and N-cadherin. This often makes DSIE misdiagnosed as a malignant tumour of the digestive system in clinical practice. In addition to surgery, novel treatments are urgently required to effectively eradicate this lesion.

Endometriosis as an Uncommon Cause of Intestinal Obstruction-A Comprehensive Literature Review

The prevalence of intestinal endometriosis has been estimated to be between 3% and 37% of all endometriosis cases. Cases of intestinal occlusion due to endometriosis foci on the small bowel and on the large bowel are even rarer, with a reported prevalence of 0.1-0.7%. The aim of this literature review was to summarize the available published evidence on the diagnosis, characteristics, and management of intestinal occlusion due to endometriosis. The search on PubMed retrieved 295 records, of which 158 were rejected following a review of the title and abstract. After reviewing the full text, 97 studies met the Population, Intervention, Comparator, Outcomes, and Study (PICOS) criteria and were included in the analysis. The total number of patients with bowel occlusion due to endometriosis included in the studies was 107. The occlusive endometrial foci were localized on the ileum in 38.3% of the cases, on the rectosigmoid in 34.5% of the cases, at the ileocecal junction and the appendix in 14.9% of the cases, and at the rectum in 10.2% of the cases. Only one case reported large bowel obstruction by endometriosis of the hepatic flexure of the colon extending to the transverse colon (0.9%), and in one case the obstruction was caused by an omental giant endometrioid cyst compressing the intestines. We identified six cases of postmenopausal females with acute bowel obstruction due to endometriosis. Malignant degeneration of endometriosis was also identified as a cause of intestinal occlusion. The mechanisms of obstruction include the presence of a mass in the lumen of the intestine or in the wall of the intestine, extrinsic compression, adhesions, or intussusception.

Sox-2 positive cells identified in lymph nodes from endometriosis patients may play a role in the disease pathogenesis

OBJECTIVE

This study aimed to characterize Sox-2 in sentinel lymph nodes and randomly obtained lymph nodes from endometriosis (EM) patients for the first time.

STUDY DESIGN

This prospective study analyzed tissue samples from surgical specimens collected from May until December 2007 in the Endometriosis Center Charité, Berlin. Lymph node samples from 38 women aged between 22 and 49 years who underwent laparoscopy due to symptomatic EM were analyzed. The material was obtained either randomly or, in the case of deep infiltrating endometriosis, detected using 4 cc Patent Blue®, labeled intraoperatively, which made the sentinel lymph nodes available for histological examination. Together with hematoxylin and eosin staining, the sections were evaluated by immunohistochemistry with antibodies against estrogen and progesterone receptors and Sox-2. Using double-immunofluorescence microscopy, the colocalization of Sox-2 and estrogen receptors were evaluated.

RESULTS

Sox-2-positive cells were identified in the lymph nodes' cortical and medullary zones, with a higher expression in the medullary layer. Occasionally, Sox-2 positive stained cell groups, called cell nests, could also be detected. The number of Sox-2 positive cells in the sentinel lymph nodes was almost three times higher than in the random lymph nodes (p = 0.031). A significant five-fold increase (p = 0.0013) in Sox-2 expression was seen in the estrogen and progesterone receptor (ER/PR) positive patient group compared to the progesterone receptor positive group or hormone receptor negative patients. Identical hormone-related Sox-2 expression was also detected separately for the sentinel lymph node group (p = 0.0174). Sox-2 showed pronounced colocalisation with estrogen receptors.

CONCLUSION

The lymphatic involvement in EM is evidence of a systemic disease manifestation and provides evidence of an immune system failure. In recent years, many theories have been studied, but there is no single theory that could explain all aspects of EM. The future concept of EM is likely to incorporate the elements from all the pathogenetic theories already described. Through this study, stem cells and lymphatic metastasis theories were incorporated.

Endometrioma causing recurrent small bowel obstruction in a virgin abdomen-a case report and literature review

There has been a modest number of cases of bowel obstruction secondary to endometriosis reported. Delays in diagnoses can cause significant morbidity to patients. We describe the case of a 45-year-old female with a 2-year history of recurrent small bowel obstructions (SBOs) without a history of abdominal surgery. She underwent multiple computed tomography scans, and a magnetic resonance enterography, which queried possible terminal ileitis secondary to Crohn's fibro-stenosing disease or a Meckel's diverticulum. Colonoscopy up to TI was normal. Elective laparoscopy showed a cicatrizing small bowel mass in her distal ileum ~15 cm from the TI, which was resected. There were no other findings. Histopathological testing revealed endometriosis. At 2-month post-resection, she remains symptom-free and was referred to gynaecology. Endometriosis causing bowel obstruction should be considered early in female patients, especially those with virgin abdomens. Timely elective laparoscopy is a safe and effective way of diagnosing and treating small bowel obstruction, avoiding an emergency procedure.

Small bowel obstruction caused by appendiceal and ileal endometriosis: a case report

Endometriosis is characterized by the presence of an ectopic endometrial gland. Intestinal endometriosis with small bowel obstruction is uncommon. In this case, a 37-year-old woman with no history of endometriosis presented with a chief complaint of abdominal pain. Computed tomography revealed a distal small bowel obstruction. Surgical intervention was performed because of the emergent abdominal condition and the potential resistance to conservative management. Histopathological examination revealed appendiceal and ileal endometriotic lesions. Preoperative diagnosis was difficult because there were no specific clinical features. Intraoperatively, it is difficult to distinguish intestinal endometriosis and bowel malignancy; thus, oncological resection should be performed.

Rare Case of Ileocecal Obstruction Secondary to Endometriosis Presenting for the First Time

Though endometriosis involving the intestines is well known, it causing ileocecal obstruction is a rare presentation. Etiology for ileocecal obstruction may not be known in all the cases preoperatively and may sometimes need resection and histopathology for diagnosis. Here we present a case of endometriosis presenting for the first time as an ileocecal obstruction in a 39-year-old lady who presented to us with complaints of intermittent abdominal pain. Contrast CT scan of the abdomen showed terminal ileal stricture and wall thickening. She underwent diagnostic laparoscopy, which showed dilated distal small bowel loops with suspicious stricturing growth at the terminal ileum and ileocecal valve region. A formal laparoscopic right hemicolectomy was done and post-operative histopathology revealed endometriosis with fibrosis, causing a luminal obstruction. In conclusion, endometriosis should be considered as a rare differential in patients presenting with ileocecal obstruction and having inconclusive features on imaging, endoscopic or biopsy, especially in women of childbearing age.