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ENDOMETRIOSIS MIMICKING SYMPTOMS OF MICROPERFORATION IN A TEENAGE GIRL WITH INFLAMMATORY BOWEL DISEASE
H Evangeliou, S MacDonald, M Blumenkrantz, V MorinvilleMontreal Children's Hospital, McGill University Health Centre, Montreal, QC
Aims: Crohn's disease (CD) and Ulcerative Colitis (UC) are systemic conditions that can cause both local intestinal and more distant complications. However, not all abdominal symptomatology in a patient known for inflammatory bowel disease (IBD) is necessarily related to the condition itself. We hereby report a case of a teenage girl diagnosed with UC at age 15, who presented with cyclic episodes of peritoneal symptoms, initially attributed to potential microperforations, but subsequently diagnosed with serosal endometriosis.
Methods: Chart review.
Results: A 16-year-old girl was hospitalized three times over a nine-month period for episodes of severe, sudden onset abdominal pain with peritoneal signs. Her past medical history was significant for a diagnosis of pancolitis UC at age 15, initially treated with steroids and immunomodulator. Despite the diagnosis of UC and the patient being well in between episodes, the recurrent presentations were felt to be concerning for mis-labelled CD complicated by microperforations. The patient was managed with bowel rest, intravenous antibiotics and steroid therapy on each occasion. The proposed diagnosis began to be questioned as several ancillary tests did not suggest CD: cross-sectional imaging did not demonstrate fistulizing disease; repeat gastroscopy, colonoscopy and capsule endoscopy failed to reveal small bowel involvement; and antibody serologies were consistent with UC. Upon review of history, pain crises were found to be cyclical, corresponding to menses or missed menstrual cycles. Pelvic magnetic resonance imaging search for endometriosis was negative, but showed non-specific inflammation of the right lower pelvis. Due to ongoing symptoms, the patient underwent a diagnostic laparoscopy, with findings of a macroscopically diseased appendix. Appendectomy pathologic specimen revealed serosal endometriosis. The patient was placed on continuous oral contraceptive pill hormonal therapy and cyclical crises ceased.
Conclusions: IBD may present a myriad of symptoms and complications. This case highlights the importance of considering non-IBD related diagnoses, especially if the clinical presentation is unusual. Bowel endometriosis may present with peritoneal symptoms and occasionally may be found in the appendix (prevalence of appendiceal location in bowel endometriosis estimated at 5% to 18%). Magnetic resonance imaging frequently confirms the diagnosis, but gold standard remains laparoscopic examination. Endometriosis is not believed to be related to IBD, but has occasionally been described as a mimicker of IBD, either at initial presentation or subsequently, as in our patient. Treating physicians must remain vigilant to consider endometriosis as a possible etiology in females with IBD presenting with peritoneal signs.