St. Luke's University Health Network Allentown, PA
Janak Bahirwani, MD1, Dhruv Patel, MD2, Lisa Stoll, MD, MPH3, Sarina Kapoor, MD2; 1St. Luke's University Health Network, Allentown, PA; 2Saint Luke's GI Specialists, Fountain Hill, PA; 3Saint Luke's, Bethlehem, PA
Introduction: Endometriosis is the ectopic implantation of endometrial tissue in other sites. Ectopic tissue can be commonly endo-pelvic but relatively rarely is located extra-pelvic. Gastro-intestinal endometriosis usually presents with altered bowel habits, rectal bleeding or dyschezia and most commonly involves the recto-sigmoid. Involvement of the cecum is rare. We present a young female with an abnormal computerized tomography (CT) scan, revealing cecal volvulus on colonoscopy, managed by a right hemicolectomy identifying endometriosis.
Methods: A 44 year old female with Irritable Bowel Syndrome and obesity presented with diffuse abdominal discomfort and an abnormal CT of her abdomen. Physical exam and labs were within normal limits. CT showed a left renal cyst and a filling defect with concern for a mass in the cecum. A colonoscopy was performed, which showed a mal-rotated/twisted cecum with a possible underlying submucosal lesion and granular tissue. The appendiceal orifice was unable to be located. Biopsies obtained showed focal mild active colitis with no evidence of dysplasia/malignancy. She underwent a magnetic resonance enterography which showed a solid enhancing mass at the cecal tip measuring 3.4 x 2.5 x 3.4 cm. The decision was made to pursue laparoscopy, which revealed a puckered mass of the cecum near the base of appendix concerning for invasive malignancy. Surgical pathology showed extensive endometriosis of the colonic wall and 2 pericolic lymph nodes, highlighted by PAX8, CK7 and absent CK20 expression. She was started on oral contraceptive pills for management of endometriosis. Discussion: This case is rare because endometriosis presenting as cecal volvulus has been reported only once in literature. It highlights the importance of considering extra-pelvic endometriosis in the differential of abdominal pain in young females. Management of colonic endometriosis can be medical or surgical. If biopsies from colonoscopy demonstrate endometriosis non-surgical options include hormonal therapy. However, superficial gastrointestinal biopsies may be inadequate to diagnose colonic endometriosis and deeper tissue sampling techniques may be required to establish a diagnosis of suspected endometriosis.Our patient was managed with a right hemi-colectomy because of non diagnostic biopsies concern for malignancy on ileocolonic imaging. Post-operatively she decided to pursue hormonal therapy rather than salphingo-oophorectomy.
Puckered cecum seen during laparoscopy
Low (5X): Benign colonic mucosa with submucosal High (20X): Benign submucosal endometrial glands endometriosis consisting of benign glands and stroma and stroma
Disclosures: Janak Bahirwani indicated no relevant financial relationships. Dhruv Patel indicated no relevant financial relationships. Lisa Stoll indicated no relevant financial relationships. Sarina Kapoor indicated no relevant financial relationships.