Refractory epigastric pain secondary to intussusception caused by cecal endometriosis

Description

A 43-year-old woman with a right ovarian cyst presented with a 4-month history of recurrent epigastric pain and nausea once a day each month. Her symptoms spontaneously improved during each previous episode; however, the current episode was associated with the severe symptoms including epigastric pain and nausea. She underwent contrast-enhanced CT, gastroscopy and colonoscopy 1 month prior to presentation for investigation of the refractory abdominal pain. Colonoscopy revealed only a small submucosal cecal tumour but was otherwise unremarkable. However, the tumour was too small to account for her refractory abdominal pain (figure 1A). Histopathological evaluation of a biopsy specimen revealed normal mucosa. Based on her history of present illness, the cyclical epigastric pain appeared to be associated with her menstrual cycle; however, previous examination ruled out an ovarian cyst. On physical examination, her abdomen was soft and distended with localised epigastric tenderness and guarding. Body temperature was 37.3°C, and laboratory test results were unremarkable. Abdominal CT suggested intussusception of the ileum into the transverse colon (figure 1B). She underwent open right haemicolectomy, and we diagnosed intussusception of a cecal tumour (figure 1C). We performed ileocecal resection, and histopathological evaluation of the resected specimen showed cecal endometriosis (figure 1D). She was discharged on postoperative day 5 without any complications, and the epigastric pain has not recurred since.

Figure 1.

(A) Colonoscopy revealed only a small submucosal cecal tumour. (B) Abdominal CT: yellow arrowheads suggest intussusception of the ileum into the transverse colon. (C) Operative finding of emergency operation. (D) Resected specimen: cecal endometriosis was larger than submucosal tumour found on colonoscopy.

Intestinal endometriosis is an extremely rare type of extragenital endometriosis, and cecal endometriosis accounts for approximately 3%–10% of all varieties of gastrointestinal endometriosis.¹ Optimal treatment of cecal endometriosis remains unknown. Medical therapy is recommended for endometriosis of the sigmoid colon and the rectum; however, its efficacy for other types of intestinal endometriosis remains unclear.² Surgical resection is recommended for symptomatic patients who are refractory to medical therapy.²

Intussusception in adults is rare. It contributes to approximately 5% of all cases of intussusception and is associated with malignant tumours in most cases.³ Intussusception secondary to cecal endometriosis as observed in our patient is extremely rare. However, physicians must consider intestinal endometriosis in the differential diagnosis in premenopausal women with refractory abdominal pain, particularly among those with positive findings on colonoscopy. The submucosal tumour was too small to explain our patient’s symptoms; however, it is likely that menstrual cycles can cause changes in tumour size. Detailed history taking confirmed the correlation between the patient’s menstrual cycles and symptomatic pain cycles to accurately diagnose refractory abdominal pain in this case.

Learning points.

• Detailed history taking in premenopausal women can help diagnose repeated abdominal pain associated with endometriosis.

• Menstrual cycles can cause changes in tumour size of cecal endometriosis.

• Physicians should consider intussusception caused by cecal endometriosis as a differential diagnosis, even if submucosal cecal tumour is small.

Ethics statements

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