Transmural Polypoid Endometriosis of the Sigmoid Colon

  • Daryl Ramai
  • Sandars Linn
  • Tyler Murphy
  • Madhavi Reddy
GI Image
A 48-year-old female presented with a history of chronic constipation and intermittent lower gastrointestinal bleeding after bowel movements. She reported that bleeding began in her 20’s but recently started experiencing constipation. She denied any associated fever, chills, or weight loss. The patient denied smoking, alcohol, and illicit drug use. Physical examination was normal. Pertinent laboratory tests were within reference range. Colonoscopy was performed which revealed mild melanosis in the sigmoid colon. A 4-cm recto-sigmoid polypoid lesion with overlying normal mucosa was identified and biopsied (Fig. 1a). Biopsy showed fragments of colonic mucosa with no significant pathologic findings. Endoscopic ultrasound (EUS) demonstrated a mass in the recto-sigmoid colon arising from the muscularis propria of the colon (Fig. 1b). The mass was hypoechoic and measured 15.5-mm on the long axis and 6.2-mm on the short axis. Invasion into the serosa was also noted, as well as no evidence of adenopathy (T4 by EUS criteria). The patient subsequently underwent an exploratory laparotomy and procto-sigmoidoctomy for resection of the recto-sigmoid mass measuring 10-cm in length by 5-cm in average circumference (Fig. 2). Surgical histopathology of the sigmoid mass revealed endometriosis present in the submucosa, muscularis propria, and infiltrating into the sub-serosa.
Fig. 1

a A 4-cm polypoid mass in the recto-sigmoid junction with normal-appearing mucosa. b Endoscopic ultrasound (EUS) showing a hypoechoic mass measuring 15.5-mm on the long axis and 6.2-mm on the short axis in the recto-sigmoid colon, and arising from the muscularis propria (MP)

Fig. 2

Gross surgical pathology of the recto-sigmoid mass measuring 10-cm in length by 5-cm in average circumference, and showing polypoid endometriosis (arrows)

Endometriosis is most commonly found in the genital organs and pelvic peritoneum, but rarely occurs in the gastrointestinal tract. The clinical presentation of intestinal endometriosis varies from abdominal cramps, rectal bleeding, bowel obstruction, and rarely with perforation or malignant degeneration.1 Intestinal endometriosis represents a diagnostic challenge to clinicians as it may be mistaken for neoplasms, ischemic colitis, inflammatory bowel disease, post radiation colitis, diverticular disease, or infection.2 The majority of patients with intestinal endometriosis are diagnosed with laparoscopy or laparotomy. Treatment of gastrointestinal endometriosis includes surgery, pain management, or hormonal manipulations.3 However, due to a high recurrence rate, surgery is considered the treatment of choice, especially in young patients and those with severe symptoms Fig 3.
Fig. 3

a Endometriosis seen in the submucosa (× 20). b Endometriosis seen in the muscularis propria (× 20). c Endometriosis seen in the muscularis propria (× 40). d CD10 positive endometrial stroma (× 40)


Authors’ contribution

DR, SL, and MR conceived and designed the report; DR drafted the article; TM acquired images; SL, DR, TM, and MR critically revised the article for important intellectual content; all authors gave final approval of the article.

Compliance with Ethical Standards

Conflicts of Interest

The authors declare that they have no conflict of interest.

Informed Consent



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Copyright information

© The Society for Surgery of the Alimentary Tract 2018

Authors and Affiliations

  1. 1.Division of Gastroenterology and Hepatology, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai HospitalThe Brooklyn Hospital CenterBrooklynUSA
  2. 2.School of MedicineSt George’s UniversityTrue BlueGrenada

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