Postmenopausal intestinal obstructive endometriosis : case report and review of the literature

Sao Paulo Med J. 2008;126(3):190-3. C a s e R e p o r t Pedro Popoutchi Carlos Renato dos Reis Lemos Julio César Rosa e Silva Antônio Alberto Nogueira


INTRODUCTION
Endometriosis is an estrogen-dependent disease that usually occurs in women during the menacme.2][3] However, occurrences of endometriosis in patients with no menstrual fl ow, 4,5 or the presence of lesions at sites where there is no direct contact with menstrual fl ow, such as the lungs and intestine, 6,7 raise the hypothesis that metaplasia may develop in these areas and/or vascular transport may occur, especially if estrogen is not present.
The incidence of intestinal endometriosis ranges from 3 to 34%, [8][9][10] and the sigmoid and rectum are more commonly involved.This disorder is more frequent among women during the menacme 6 and its importance lies mainly in the need for a differential diagnosis with colon adenocarcinoma, which is the third most common type of cancer diagnosed in women. 11he objective of the present report was to describe and discuss a rare case of postmenopausal intestinal endometriosis simulating a malignant lesion, with emphasis on diagnostic and therapeutic methods, following a review of the literature.

CASE REPORT
A 74-year-old white woman from Itabuna, State of Bahia, Brazil, sought the Coloproctology Service of our institution with complaints of hematochezia and liquid feces of two months' duration, as well as tenesmus and pelvic pain.
Her antecedents of interest included eight pregnancies, two abortions, six vaginal deliveries, menopause of 22 years' duration, presence of diabetes and hypertension, and no hormone replacement treatment.She reached the menarche at 13 years of age, and did not have any history of dysmenorrhea.She had undergone hysterectomy plus bilateral salpingo-oophorectomy three years before her referral to our service, due to endometrial thickening, with a postoperative anatomopathological diagnosis of endometrial glandular hyperplasia and discrete cellular atypia.On the same occasion, a mass of chocolate-colored content that occluded the upper third of the vagina and a paratubal cyst also containing chocolate-colored matter had been detected intraoperatively.Histological analysis led to a diagnosis of hematosalpinx with hemosiderin on the left side.
Five months before before her referral to our service, she was attended at the emergency service of Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (HC/FMRP/USP) with signs and symptoms of intestinal obstruction.She underwent exploratory laparotomy, which revealed a tumor mass surrounding some loops of the small intestine.Anatomopathological examination confi rmed the presence of intestinal endometriosis.
Physical and proctological examinations gave normal results, except for grade II obesity.Colonoscopy was requested (Figure 1), which revealed a friable and stenosing tumor formation in the upper rectum.A biopsy revealed mucosal fragments of endometrial type.Tomography of the pelvis (Figure 2) only showed parietal thickening in the rectosigmoid transition.
In view of the obstructive nature of the lesion, surgical treatment was chosen.This revealed a fi brous mass measuring 4 cm in diameter in the rectum.Abdominal rectosigmoidectomy was then performed with a low mechanical colorectal anastomosis and transversostomy in a protective loop (Figure 3).The anatomopathological examination confi rmed the presence of extensive transmural intestinal endometriosis (Figure 4).The patient had a satisfactory postoperative course.Four months later, during a control colonoscopy, a winecolored polyp was observed in the colorectal anastomosis (Figure 5) and was excised.

REFERENCES
Anatomopathological examination confirmed recurrence of the disease, which caused aggressive stenosis of the anastomosis despite new transanal resections and dilatations.The patient has remained colostomized since then, and has not been in a suitable condition for intestinal transit reconstruction.

DISCUSSION
][10] The rectum, sigmoid colon, vermiform appendix, terminal ileus and cecum are the most affected segments, in decreasing order of occurrence. 10,12he main symptoms are abdominal or pelvic pain, rectal pain, dysmenorrhea, dyspareunia, constipation, tenesmus and rectal bleeding.More than 90% of these patients report some type of abdominal pain, while only 20% complain of rectal bleeding. 10The symptoms are usually more marked during the menstrual period, but may also occur at any other time. 13olorectal endometriosis is predominantly subserosal, rarely involving the muscularis or the mucosa.Colonoscopy is not always useful, but is of benefit by ruling out other lesions such as adenocarcinomas.Among the imaging examinations, endorectal ultrasound is particularly important.This has better sensitivity and specificity than computed tomography (CT) and nuclear magnetic resonance (NMR). 14e differential diagnoses of colonic lesions include adenocarcinomas, sarcomas, lymphomas, carcinomas and intestinal endometriosis. 5In cases of intestinal endometriosis, the need for colectomy ranges from 0.1 to 0.7% of the cases 8 since the rate of endometrial carcinomas in ectopic endometrial tissue is very low.The presence of pelvic pain refractory to clinical treatment that originates in lesions of intestinal endometriosis and the obstructive nature of the disease are some of the few justifications for the procedure. 10,12,13In the present case, the decision to proceed with surgery was due to the stenosing nature of the lesion.
Hormonal treatment should be considered for childless young women, since this may lead to disappearance or reduction of the colorectal symptoms. 10Surgical treatment should be instituted when the response to conservative treatment is inadequate or there are contraindications.In selected patients, intestinal resection in combination with hysterectomy plus bilateral salpingo-oophorectomy has yielded the best results. 10n advanced cases with extensive pelvic and rectal involvement, fibrosis and ureteral involvement usually impair the use of surgery, with frequent need for low resections and a protective stoma.Thus, in these cases, for better control over the disease, we chose hysterectomy plus bilateral salpingo-oophorectomy in combination with rectal surgery.
The peculiar feature of the present case was the difficulty in explaining the appearance of the lesion in a patient who had been in a hypoestrogenic condition for 22 years and had undergone hysterectomy and oophorectomy three years before the present event.Moreover, she had no history suggesting the presence of endometriosis during the menacme (pelvic pain or infertility).In a case of this type, the hypothesis of intestinal tissue metaplasia should be considered. 15dvanced disease has been more strongly associated with pure or mixed undifferentiated disease.The results of Abrão et al. demonstrated that advanced disease with a worse outcome is related to higher prevalence of an undifferentiated pattern. 1

CONCLUSION
The present case cannot be explained by currently accepted theories for the etiopathogenesis of endometriosis (retrograde flow and immunological theories).Histopathologically advanced disease and more aggressive degrees of undifferentiation may explain the lower hormonal dependence with appearance of the disease during the postmenopausal period.This case emphasizes the difficulty in making a differential diagnosis with colorectal neoplasia, in view of the aggressive and recurrent nature of this disease following the menopause.

Figure 1 .
Figure 1.Computed tomography of the abdomen and pelvis of a 74-years-old woman, showing parietal thickening in the rectosigmoid transition.

Figure 2 .
Figure 2. Preoperative colonoscopy, showing friable and stenosing tumor formation in the upper rectum.

Figure 5 .
Figure 5. Colonoscopy in the fourth postoperative month after rectosigmoidectomy.