The Egyptian Journal of Radiology and Nuclear Medicine 47 (2016) 1783–1786

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Case Report

Gastric wall endometriosis in a postmenopausal woman

Abdallah A.A. Mohamed a,⇑, Yasser A.R.M. Selim a,1, Mazin A. Arif b,2, Said A. Albroumi b,2
a
Radiology Department, Nizwa Hospital, P.O. Box 1222, Nizwa PC 611, Oman
b
General Surgery Department, Nizwa Hospital, P.O. Box 1222, Nizwa PC 611, Oman

a r t i c l e i n f o a b s t r a c t

Article history: Endometriosis is the presence of endometrial tissue outside of the uterus. It is common in
Received 11 July 2016 women of childbearing age, and is frequently located in the pelvic cavity. Approximately
Accepted 14 August 2016 10% of endometriosis cases occur in extrapelvic locations. However there are few reports
Available online 8 September 2016
of gastric wall endometriosis. Here, we report a rare case of endometriosis in post-
menopausal woman. The patient presented with epigastric pain. The investigations
Keywords: included ultrasound (US) and contrast enhanced computed tomography (CECT) where
Endometriosis
she was diagnosed with gastric wall neoplasm. She underwent surgery where the mass
Postmenopausal
Computed tomography
was excised. The histopathological examination surprisingly came with the diagnosis of
Laparotomy gastric wall endometriosis.
Ó 2016 The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by
Elsevier. This is an open access article under the CC BY-NC-ND license (http://creativecom-
mons.org/licenses/by-nc-nd/4.0/).

1. Introduction Extrapelvic endometriosis frequently includes the

intestines, kidneys, lungs, skin, and pleura [4]. Gastroin-
Endometriosis is identified as the presence of endome- testinal tract (GIT) endometriosis accounts for almost 5%
trial tissue in an ectopic location outside of the endome- of cases, with the sigmoid colon and rectum being the most
trial cavity. It is a benign chronic gynaecological disorder commonly affected locations [5].
which may be associated with infertility. The disease is Here we report a case of gastric endometriosis that pre-
oestrogen-dependent that usually affects women in repro- sented as a gastric neoplasm in postmenopausal woman
ductive age. The prevalence of pelvic endometriosis is with no history of exogenous hormonal therapy.
approximately 6–10% [1]; however, the presence of
extrapelvic endometriosis is seen only in 10% of all 2. Case report
diagnosed cases. The prevalence of endometriosis in
postmenopausal women can affect 2–5% [2] and usually A 60 year old female patient presented with increasing
as a side effect of hormonal therapy and it is rare to present epigastric pain and left loin pain associated with nausea
in postmenopausal women without history of hormonal since long time. She is a known hypertensive on regular
therapy [3]. medications. She has chronic epigastric pain since long
time for which she underwent upper GI endoscopy in
Peer review under responsibility of The Egyptian Society of Radiology and February 2014 which revealed diffuse gastritis, and the
Nuclear Medicine. patient received full regimen proton pump inhibitors with
⇑ Corresponding author. Fax: +968 25211914. little improvement. No family history of special impor-
E-mail addresses: [email protected] (A.A.A. Mohamed),
tance. A physical examination revealed mild epigastric
[email protected] (Y.A.R.M. Selim), [email protected]
(M.A. Arif), [email protected] (S.A. Albroumi). and left loin tenderness, not dyspneic or tachypneic. Chest
1
Fax: +968 25211914. was clear. BP was 130/80 mm/Hg, temperature was
2
Fax: +968 25211909. 36.8 °C, and her biochemical and haematological markers

http://dx.doi.org/10.1016/j.ejrnm.2016.08.005
0378-603X/Ó 2016 The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1784 A.A.A. Mohamed et al. / The Egyptian Journal of Radiology and Nuclear Medicine 47 (2016) 1783–1786

Fig. 1. CECT of the abdomen and pelvis in coronal plan, shows gastric Fig. 3. CECT of the abdomen and pelvis in coronal reformat, shows left
antral wall mass lesion with inhomogeneous enhancement. lower ureteric stone with subsequent moderate hydroureteronephrosis.

large, irregular, inhomogeneously enhancing soft tissue

mass involving the inferior wall of the gastric antrum with
large exophytic component and few satellite nodules with
possible involvement of transverse colon. The mass mea-
sures 4.5 cm  6.5 cm  4.5 cm. The impression suggested
gastrointestinal stromal tumour (GIST) and Desmoid
tumour on top of differential diagnosis [Figs. 1 and 2]. Also,
a left lower ureteric stone with subsequent moderate
hydroureteronephrosis was noted [Fig. 3].
The patient underwent exploratory laparotomy where
excision of the mass with sleeve gastrectomy of the greater
curvature together with partial transverse colectomy fol-
lowed by resection anastomosis of the two colonic ends.
The excised surgical specimen was 8 cm  5 cm. There
were also three satellite lesions in the greater omentum
which had been removed with the specimen [Fig. 4].
Histopathological examination revealed extensive areas
of haemorrhage and haemorrhagic necrosis. These are sep-
arated and bordered by proliferation of spindle cells and
admixture of foamy macrophages and haemosiderin laden
macrophages. Scanty lymphoid cells are also seen [Fig. 5].
The lesion is seen extending up to the serosa of the stom-
ach and the colon with serositis. The spindle cells stain
positively with CD 10 and SMA [Fig. 6]. They are negative
for CD 117, desmin, S-100 and CD34. The diagnosis based
on morphological and immunohistochemical features
Fig. 2. CECT of the abdomen and pelvis in sagittal plan, shows gastric favours endometriosis.
antral wall mass lesion with inhomogeneous enhancement.

were within normal limits. Abdominal ultrasonography 3. Discussion

showed gastric antral mass lesion and left ureteric stone
associated with moderate hydroureteronephrosis. CECT of Endometriosis is the presence of endometrial tissue in
the abdomen and pelvis was performed which revealed a an ectopic location outside of the endometrial cavity. It is
 A.A.A. Mohamed et al. / The Egyptian Journal of Radiology and Nuclear Medicine 47 (2016) 1783–1786 1785

Fig. 4. Surgical specimen after resection of the mass lesion.

Fig. 5. H&E stain showing evidence of old and recent haemorrhage.

Fig. 6. Histopathology specimen with CD10 immuno-marker.

a benign chronic gynaecological disorder which may be period. The prevalence of pelvic endometriosis is
complicated by infertility. The disease is oestrogen- approximately 6–10% [1]. However the presence of
dependent that usually affects women in childbearing extrapelvic endometriosis is seen only in 10% of all cases.
1786 A.A.A. Mohamed et al. / The Egyptian Journal of Radiology and Nuclear Medicine 47 (2016) 1783–1786

The prevalence of endometriosis in postmenopausal 4. Conclusion

women is a rare condition and may affect 2–5% [2] and
usually as a side effect of hormonal therapy and it is even Extrapelvic endometriosis is rare and can affect unusual
rarer to present in postmenopausal women without his- sites. Gastric wall endometriosis is extremely rare in a
tory of hormonal therapy [3]. It was first reported in 1950. postmenopausal woman, it may mimic gastric wall neo-
Frequent locations of extrapelvic endometriosis include plasm and it should be included in the differential diagno-
the intestines, kidneys, lungs, skin, and pleura. GIT sis of gastric masses in women with chronic and cyclic
endometriosis accounts for almost 5% of cases, with the epigastric pain.
sigmoid colon and rectum being the most commonly
affected locations [5]. Disclosure
The pathogenesis of endometriosis still unclear, how-
ever, several theories to explain the pathogenesis were We declare no conflict of interests prior and during
suggested which include; coelomic metaplasia which preparation of this paper.
may be caused by inflammation and hormonal effect, and
this theory may explain the pathogenesis of the disease Acknowledgments
following hysterectomy, in postmenopausal women and
in women with uterine agenesis [6,7]. Another theory is We would like to thank the staff of histopathology
endometrial stem cells implantation from vascular department at the Royal Hospital, Muscat, Oman for their
endometrial cell transportation, and this theory may contribution.
explain extra pelvic endometriosis [8,9].
The present case is a very rare case of extrapelvic, gas- References
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