Nongynecological endometriosis presenting as an acute abdomen

Acute abdominal pain in women of reproductive age: keys to suggest a complication of endometriosis

Although endometriosis is a common gynecological condition in women of reproductive age, a complication of endometriosis is rarely considered as the differential diagnosis of acute abdominal pain in that context. However, acute events in women with endometriosis can represent life-threatening conditions, which require emergent treatment and often surgical management. Mass effect of endometriotic implants can give rise to obstructive complications, specifically occurring in the bowel or in the urinary tract, while inflammatory mediators released by ectopic endometrial tissue can lead to inflammation of the surrounding tissues or to superinfection of the endometriotic implants. Magnetic resonance imaging is the best imaging modality to reach the diagnosis of endometriosis, but an accurate diagnosis is possible on computed tomography, especially in the presence of stellar, mildly enhanced, infiltrative lesions in suggestive areas. The aim of this pictorial review is to provide an image-based overview of key findings for the diagnosis of acute abdominal complications of endometriosis.

Appendiceal intussusception from endometriosis

An asymptomatic 39-year-old woman was noted to have occult bleeding by faecal immunohistochemical test. Investigations showed a 3 cm×2 cm caecal lesion by colonoscopy that was consistent with abdominal CT scan findings of a 1.6 cm×1.9 cm×2.3 cm enhancing focus in the medial caecal wall. The patient underwent laparoscopic right hemicolectomy after diagnostic laparoscopy and intraoperative colonoscopy revealed an intussuscepted appendix. The final histopathology was an appendiceal intussusception secondary to endometriosis.

Two Cases of Endometriosis in the Cecum Detected by Contrast-enhanced Computed Tomography with Air/Carbon Dioxide Insufflation

We herein report two patients with endometriosis in the cecum. Both patients presented with a protruding, subepithelial tumor on colonoscopy and were diagnosed with cecal endometriosis after surgical resection. It is notable that the cecal lesions were not initially identified on computed tomography (CT), while CT colonography with air/carbon dioxide insufflation resulted in the detection of the cecal tumor. These cases highlight the possibility of false-negative results on conventional CT in patients with cecal endometriosis. We consider CT colonography with air/carbon dioxide insufflation useful for detecting cecal tumors in such cases.

Unmasking the great masqueraders: Concurrent isolated large cecal endometrioma and solitary extra-uterine retroperitoneal cellular leiomyoma - A case report with review of literature

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Bowel involvement in endometriosis is rare. Cecal endometriosis is seen in just 3.5 % of patients with bowel involvement. Patients with bowel involvement typically also have associated ovarian &/or extra-ovarian pelvic endometriosis. This case is the rarest of rare cases in that the patient had isolated cecal endometriosis without any obvious pelvic disease.

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This is the largest reported size of a cecal endometrioma (8 × 6 cms), to the best of our knowledge.

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Extra-uterine cellular leiomyoma also known as ‘wandering fibroid’ & ‘parasitic leiomyoma’ is again an extremely rare neoplasm. There are very few reported cases of parasitic leiomyoma.

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Another rarest of rare event is the concurrent existence of the 2 above mentioned conditions in the same patient.

Introduction

Cecal endometriosis is an infrequent cause of right iliac fossa pain. The extra-uterine retroperitoneal cellular leiomyoma is a rare tumor. The concurrent existence of both these rare conditions is a unique event.

Presentation of case

We hereby report the case of a 44-year-old woman who had concurrent large isolated cecal endometrioma, which was diagnosed pre-operatively on imaging to be pelvic endometriosis/hematosalpinx and solitary retroperitoneal cellular leiomyoma, which was incidentally identified. Both the conditions were managed successfully by laparoscopy.

Discussion

Cecal endometriosis is difficult to diagnose pre-operatively as there are far commoner clinical conditions that cause similar signs and symptoms. Often it gets mistaken for these conditions and gets diagnosed incidentally ‘on table’ during surgeries being performed purportedly to treat them.

Conclusion

Although definitive diagnosis can only be obtained after histopathology, laparoscopy can be considered a standard diagnostic modality for both these conditions.

Endometriosis of the Vermiform Appendix Presenting as Acute Appendicitis

Endometriosis is characterized by the growth of endometrial tissue outside the uterine cavity. Endometriosis of the appendix is rare and its preoperative diagnosis is difficult. We report the case of a postmenopausal woman who presented with right lower quadrant abdominal pain concerning for acute appendicitis. Histopathological examination of her appendix revealed endometriosis and her abdominal pain resolved after appendectomy.

Endometriosis Mimicking a Cecum Mass with Complete Bowel Obstruction: An Infrequent Cause of Acute Abdomen

Endometriosis is a common entity among fertile women which unfortunately manifests through variable symptomatology. Intestinal involvement in endometriosis is quite common and can simulate several diseases such as Crohn's disease, appendicitis, tubo-ovarian abscess, or malignant tumors. Intestinal obstruction due to endometriosis is rare, and preoperative diagnosis is difficult because the signs and symptoms are nonspecific and can be easily confused. In the case of patients without a history of endometriosis, diagnosis is further complicated. We present a case of a 41-year-old female patient. She presented to the emergency room with complete bowel obstruction and a mass in the cecum. Surgery was decided, and the patient underwent full recovery. Endometriosis was the final diagnosis for the observed condition.

A case report of endometriosis presenting as an acute small bowel obstruction

INTRODUCTION

Endometriosis is a common and benign condition that causes significant morbidity to women of childbearing age. It uncommonly affects the gastrointestinal tract and rarely manifests as an acute small bowel obstruction.

PRESENTATION OF CASE

A 46-year old female presented to the emergency department with signs and symptoms consistent with an acute small bowel obstruction. She had a paucity of background surgical history, having only had a laparoscopic cholecystectomy. Her CT demonstrated small bowel obstruction with a transition point in the distal ileum. Given the site of obstruction was remote from previous surgery, a high index of suspicion was maintained and early laparoscopy performed the same day. Operative findings were consistent with an endometrial stricture of the distal ileum and a formal resection was performed.

DISCUSSION

Endometriosis that affects the gastrointestinal tract often presents with non-specific symptoms. This is a rare case of an acute small bowel obstruction as the index symptom of endometriosis in a peri-menopausal patient. This is the first case in the literature to describe same day laparoscopy and small bowel resection of such a case and a prolonged preoperative period and misdiagnoses previously described were avoided due to clinical suspicion.

CONCLUSION

Endometriosis as a differential should be considered with a high index of suspicion in pre-menopausal women, particularly in patients with negligible previous surgical history. There should be a low threshold for early laparoscopy and resection of affected bowel in these patients.

Emergent ultrasound evaluation of the pediatric female pelvis

Ultrasound is the primary imaging modality of the pediatric female pelvis and is often requested to evaluate girls with pelvic or abdominal pain or abnormal bleeding. The US interpretation can help guide the clinician toward medical or surgical management. Here we discuss the normal US anatomy of the female pelvis and illustrate, through case examples, conditions encountered when performing emergent pelvic US for common and uncommon clinical scenarios.

A very rare case of endometriosis presenting with massive hemoperitoneum

Endometriosis is a cause of acute abdomen because of the leakage or rupture of endometriotic cyst and tubo-ovarian abscess. However, massive hemoperitoneum as a cause of acute abdomen with endometriosis is very rare. We herein present a case of a 48-year-old woman who was urgently referred to our clinic with colic, abdominal distension, and hypovolemic shock during menstruation. Ultrasonography revealed massive hemorrhagic ascites. Exploratory laparoscopy was urgently performed to achieve hemostasis. The volume of hemoperitoneum evacuated from the pelvis was 1,890 mL. Although the uterus and bilateral ovaries were normal, fresh bleeding was observed from endometriosis on the left cul-de-sac peritoneum, and hemostasis was successfully performed. The potential occurrence of hemorrhagic shock associated with endometriosis, depending on the implantation site, needs to be recognized.

Exogenic Adenomyoma of the Cervix: Report of 2 Cases and Review of the Literature

Purpose

Exogenic adenomyoma of the cervix is very rare. To date, very few cases have been reported, and the presentation and diagnosis are not clear. The aim of this study was to present 2 cases of exogenic adenomyoma of the cervix and summarize what is known about this disease by conducting a literature review of reported findings.

Methods

The clinical data from 2 cases of women with exogenic adenomyoma of the cervix admitted to Peking University First Hospital were analyzed retrospectively, and a systematic literature review was carried out.

Results

In our cases, exogenic adenomyoma of the cervix presented as a mass with mixed solid and cystic lesions in the pelvis and could not be separated from the cervix. Postoperative examination of the surgical specimen using pathological tests confirmed the tumors were composed of a proliferation of endocervical glands and smooth muscle, based on which exogenic adenomyoma of the cervix was confirmed.

Conclusions

Exogenic adenomyoma of the cervix should be considered in the diagnosis, in cases of mixed solid and cystic pelvic masses found in close relationship with the cervix.

Endometriosis of the appendix

Purpose

Endometriosis is defined as functioning endometrial tissue outside of the uterus. Endometriosis of the appendix is uncommon. Its clinical presentation varies from asymptomatic to acute abdominal pain. The aims of this study were to describe our experience of managing patients with appendiceal endometriosis and to review the clinical characteristics of this medical condition.

Methods

Five cases of appendiceal endometriosis diagnosed between January 2007 and December 2012 were retrospectively reviewed. Patients treated for intra-abdominal endometriosis were excluded.

Results

The mean age at diagnosis was 33.8 years old. One patient was in the second trimester of pregnancy. Two patients were asymptomatic. Three patients had clinical symptoms including two with acute pain in the right lower quadrant and one with abdominal discomfort. Four patients showed appendiceal abnormalities in imaging studies including two cases of suspected mucocele and two cases of appendiceal infection. There were no suspicions of endometriosis of the appendix based on preoperative imaging studies. Three patients underwent appendectomy due to clinical symptoms, and two underwent incidental appendectomy combined with another operation. None of the patients received adjuvant therapy.

Conclusion

Appendiceal endometriosis should be included in the differential diagnosis for acute abdominal pain, especially when women of childbearing age present with clinical symptoms of acute appendicitis.

CT of the skin and subcutaneous tissues

A broad spectrum of skin and subcutaneous (SQ) findings may be discovered in the emergency setting on CT examinations. There are some findings that are directly relevant to the reason or reasons why the patient has undergone the CT examination. However, other findings may be incidental. The skin and SQ tissues are by definition on the periphery of CT images and may be overlooked by the radiologist, although findings related to them can be of clinical importance. The purpose of this pictorial essay is to present a broad spectrum of skin and subcutaneous findings which may be identified on CT examinations in the emergency setting (and in some cases nonemergently), and to briefly review the relevant imaging literature, which surprisingly is relatively limited on this topic. Categories of cutaneous and subcutaneous abnormalities that will be covered include trauma and hemorrhage, iatrogenic findings, infection, neoplasms, calcification, and other miscellaneous entities, all of which may initially present on emergency CT examinations of the body.