PICTURES IN DIGESTIVE PATHOLOGY

Deep infiltrating rectosigmoid endometriosis. Diagnostic keys

M.ª Alcázar Iribarren-Marín1, Herminia Pérez-Vega1, Manuel Martínez-Moya1, Lourdes Gómez-Izquierdo2 and Cristina Martínez-Polanco1

1Diagnostic Imaging Unit. Radiology Department. 2Pathological Anatomy Service. Hospital Universitario Virgen del Rocío. Seville, Spain

1130-0108/2014/106/3/212-213Revista española de enfeRmedades digestivasCopyRight © 2014 aRán ediCiones, s. l.

Rev esp enfeRm dig (MadridVol. 106, N.º 3, pp. 212-213, 2014

CASE REPORT

A 36 year-old woman was admitted with dysmenorrhea associated with rectal bleeding. The colonoscopy showed a stenosis at the rectosigmoid (RS) junction which did not exceed the endoscope. A barium enema (Figs. 1 A and B) showed traction of the sigmoid mucosa at the lower margin of the RS junction. CT examination (Figs. 1 C and D) showed an en-dometrial implant in the Douglas pouch, the pedicle connected to the colon wall and the “mushroom cap” configuration of the endometrial implant in the RS wall, all with a density similar to that of muscle tissue. A sigmoidectomy was performed (Fig. 2) with histological (Fig. 3) and immunohistochemical analysis, which demonstrated deep infiltrating rectosigmoid endometriosis (DIRSE) as the resulting diagnosis.

DISCUSSION

Endometriosis is defined as the presence of functioning ectopic endometrial tissue (endometrial glands and stroma) outside the uterus and at a distance from and unconnected with uterine endometrial tissue. The ectopic endometrium is sensitive to hormonal variation during the menstrual cycle. These results in chronic inflammation that is the cause of cyclic pelvic pain found in these patients. In the DIRSE, the ectopic tissue would respond to the ovarian hormonal cycles causing inflammation, bleeding, fibrosis and metaplasia or hyperplasia of the smooth intestinal muscle possibly affecting the sero-sa, submucosa and rarely the mucosa, which gives rise to a thickening of the intestinal wall and in some cases may evolve

Fig. 1. A and B. Barium enema. Filling compression defect which causes extrinsic traction of the sigmoid colon mucosa (arrows) produced by deep infiltration of endometrial wall. C and D. Abdominal CT with iodinated contrast. A. Coronal reconstruction. Right ovarian endometrioma (*). B. Sagittal reconstruction. Endometrial implant in the Douglas pouch (black arrow). Pedicle connecting the implant to the colon wall (hole arrow). Endometrial infiltration adopting the mushroom configuration (white arrows).

A B C D

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into an obstruction (1-3). The “mushroom cap” sign has been described in the presumed diagnosis because the tumor grows towards the RS colonic lumen (4). The differential diagnosis is reached from the neoplasic processes seen in this area.

REFERENCES

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delgado: diagnóstico por tomografía computarizada multicorte. Rev Esp Enferm Dig 2009;101:872-4. 4. yoon JH, Choi D, Jang kT, kim Ck, kim H, Lee SJ, et al. Depp rectosigmoid endometriosis: “mushroom cup” sing on T2-weighted MR imaging. Abdom

Imaging 2010;35:726-31.

Fig. 2. Piece removed by sigmoidectomy. A. Partial stenosis from submucosal lesion that thickens the intestinal wall affecting 10 cm of the total length of the piece and 30-40 % of the intestinal circumference which is 1.8 cm thick. The mucosa is spared. B. The cut shows a homogeneous muscle and submucosa thickening with a firm whitish consistency. Pedicle connecting the peritoneal endometrial implant (arrow). Fig. 3. Histology. A. Shows the different layers that make up the colon

wall, where there is a proliferation of the muscle layer with presence of endometrial glands. B. Magnification of the muscularis layer.

Mucosa

Submucosa

Muscularis layerMuscularis

propia

Endometrial glands

A

B