Gastrointestinal Endometriosis Causing Subacute Intestinal Obstruction with Gradual Development of Weight Loss and Misdiagnosed as Irritable Bowel Syndrome
A 44-year-old woman noted the onset of upper and lower abdominal pain associated with constipation approximately 4 years ago. Her symptoms were worse following meals, especially if they included fried foods, fatty foods, coffee or carbonated beverages. Episodes occurred every 2–3 days with occasional emesis but no history of hematemesis, melena or hematochezia. Her appetite remained good, but she noted a weight loss of 25 lb over the past year. There was no history of alcohol, coffee, aspirin or non-steroidal inflammatory medication abuse. She denied dyspareunia or painful menstrual periods. Her only operations were a cesarean section in 2003 and cholecystectomy in 2004.\nOn physical examination she appeared to be well-developed, well-nourished and in no acute distress. Her abdomen was non-tender and without palpable masses, organomegaly or distention. Right upper quadrant laparoscopy and suprapubic surgical scars were noted. Rectal examination demonstrated no masses or tenderness, with brown guaiac negative stool present in the rectal ampulla. Papanicolaou smear and gynecological examination performed by her gynecologist 1 month previously were normal. Her diagnostic work-up included normal complete blood count, liver and kidney function tests, thyroid function and C-reactive protein. Upper endoscopy and colonoscopy examinations were normal except for internal hemorrhoids. Abdominal and pelvic sonography were normal except for evidence of a prior cholecystectomy, mild fatty liver and a simple right ovarian cyst. A lactose tolerance test was positive.\nOn the basis of her symptoms and negative diagnostic work-up, the diagnoses of IBS, gastroesophageal reflux and lactose intolerance were made. Treatment with antacids and an anti-cholinergic did not provide relief. Due to her recurrent symptoms, a Computed tomography enterography examination was performed to evaluate the small intestine. This revealed a partial small bowel obstruction located approximately 5 cm proximal to the ileocecal valve (fig. ). Subsequent surgical resection and histology identified the cause of the partial obstruction to be endometriosis with focal submucosal hemorrhage and serosal scarring (fig. , fig. ). The patient became totally asymptomatic postoperatively.