Midgut Volvulus with Necrosis: A Complication of Endometriosis

Deeply infiltrating endometriosis (DIE) can involve the bowel leading to necrosis with septic shock, a rare complication occurring in 5% of endometriosis patients. This case report aims to illustrate a life-threatening complication of endometriosis, emphasizing the need for strong clinical acumen in atypical cases of endometriosis. This also highlights the need for improved noninvasive diagnostic modalities to enable earlier detection.

A 33-year-old woman with a presumed diagnosis of Crohn's disease presented to the emergency department in septic shock following six months of chronic gastrointestinal symptoms. She had previously undergone colonoscopy with biopsy showing terminal ileitis. Due to signs of peritonitis and systemic infection, she was urgently taken to the operating room and underwent an exploratory laparotomy that revealed midgut volvulus and extensive hemorrhagic necrosis. She underwent resection of necrotic bowel and cecum with end jejunostomy. Final pathology demonstrated DIE involving the bowel wall and mesentery, with no histologic evidence of Crohn's disease. Her postoperative course was complicated by prolonged intensive care unit (ICU) admission, cardiac arrest, and short bowel syndrome requiring nutritional support. Post operatively a pelvic magnetic resonance imaging (MRI) confirmed stage IV endometriosis with infiltration into the rectosigmoid. She was discharged in stable condition with multidisciplinary follow-up involving colorectal surgery, gynecology, and reproductive endocrinology.

This case illustrates a rare and severe presentation of intestinal endometriosis mimicking Crohn's disease, progressing to life-threatening bowel necrosis. It underscores the diagnostic challenges of endometriosis and the critical role of multidisciplinary care in optimizing outcomes for complex cases.