Caecal endometriosis presenting with an acute abdomen in pregnancy

Abstract

Endometriosis is defined as the presence of endometrial tissue outside the uterus, which induces a chronic inflammatory response. Its prevalence remains unknown, but it has been estimated to affect up to 10% of women of reproductive age. Although it is a benign oestrogen-dependent gynaecological condition, women may describe painful symptoms such as cyclical pelvic pain, dysmenorrhoea and dyschezia. Intestinal endometriosis may affect the ileum, appendix, sigmoid colon and rectum. It may present with a myriad of symptoms such as abdominal pain, vomiting, diarrhoea, constipation and haematochezia. Caecal endometriosis can present as an acute appendicitis, making the diagnosis challenging to establish in pregnancy. Transmural involvement and acute occlusion are very rare events. The gold standard for diagnosis remains laparoscopy with tissue sampling for histological confirmation. Although endometriosis improves during pregnancy under the effect of progesterone, the ectopic endometrium becomes decidualised with a progressive reduction in size. The authors present the case of a multiparous woman in her mid-30s with acute onset of right-sided abdominal pain at 35 weeks gestation. Physical examination was suggestive of an acute appendicitis and MRI showed an inflamed caecum. She became acutely unwell requiring an emergency caesarean section. A mass in the caecum was observed with impending perforation at the caecal pole. A right hemicolectomy was performed. Histopathological examination confirmed the diagnosis of endometriosis with decidualisation. Although endometriosis improves during pregnancy, this case shows the unexpected complications of the disease and demonstrates the importance of considering endometriosis in the differential diagnosis of an acute abdomen in women of childbearing age to prevent maternal morbidity and fetal loss.

Case report: A rare cause of intestinal perforation in a third-trimester pregnant woman

“…The unclear MRI findings in our patient reflect the greater challenges faced by imaging techniques in the third trimester, as the appendix is often further cranially and atypically located because of the expansion of the uterus ( 21 ). As described in other case reports, in advanced pregnancy, the appendix can often not be reliably identified by cross-sectional imaging (MRI, CT) ( 27 , 28 ). Therefore, clinical and laboratory parameters play an important role in a possible indication of a laparoscopic intervention.…”

“…Whether deep-infiltrating endometriosis reacts differently to hormonal influences is not clear ( 29 ). Size regulation under the influence of progesterone can lead to the weakening of the intestinal wall so that, in combination with fibrosis and adhesions, perforation can be promoted ( 28 , 29 ). It is also discussed that the so-called stromal endometriosis, a histological subtype lacking glands and spiral arteries, is rather asymptomatic in non-pregnant women and can lead to growth and thus to perforation during pregnancy under the influence of hormones ( 27 ).…”

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

“…MRI rarely suggests endometriosis as the cause of acute appendicitis [ 7 , 69 ]. However, if performed, T2-weighted sequences depict a hypointense retractile mass or nodular thickening of the appendix.…”

Eine seltene Ursache des akuten Abdomens in der Schwangerschaft

“…Eine Darmperforation in der Schwangerschaft aufgrund einer extragenitalen Endometriose stellt ein sehr seltenes Ereignis dar und erfordert rasche Diagnostik und Therapie 4 5 6 . Wenngleich im vorliegenden Fall keine primäre, akute Appendizitis vorlag, führte die Dezidualisierung der Endometrioseherde unter dem Hormoneinfluss der Schwangerschaft sekundär zu einer Darmperforation und Peritonitis, deren morphologische Aspekte denen einer primären Appendizitis gleichen, sodass eine weitere Differenzierung bildgebend nicht möglich ist.…”