Chest X-ray was normal with no air under the diaphragm. Multiple fluid levels were noted on the erect abdominal film. 

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... is defined as the presence of ectopic endometrial tissue outside the lining of the uterine cavity. It is a considerably common disease and is estimated to affect between 4 and 50% females of reproductive age group [1]. The pelvic organs are most commonly affected but the bowel, urinary tract and extra-abdominal organs can also be involved [2]. Intestinal endometriosis occurs in 3 to 37% cases and is usually asymptomatic [3, 4]. The rectosigmoid is the most commonly affected region of the gut, being involved in about 70% cases. Involvement of the small bowel is much less common, occurring in only 1 to 7% cases, and is usually confined to the distal ileum [5]. Complete bowel lumen obstruction occurs in less than 1% of cases [5]. We report the case of a female with intestinal endometriosis which went undiagnosed until her third presentation to the emergency department when she presented with an acute small bowel obstruction. Involvement of the ileum, cecum and ascending colon resulted in a small bowel resection and right hemicolectomy. A 39-year-old nulliparous female presented to our Emergency Department on three occasions over a period of three weeks. On the first two presentations the patient had cramping generalized abdominal pain associated with nausea. She suffered from dysmenorrhoea and menorrhagia but described the pain to be worse and more generalized than her regular menstrual pain. She did not have any other notable symptoms particularly no gynaecological symptoms. The patient was previously well with no past medical history of note, including no previous abdominal surgery. She was not on the oral contraceptive pill. Investigations included routine bloods tests, including inflammatory markers, which were normal on both previous occasions. Abdominal X-ray showed fecal loading, particularly in the ascending colon but no evidence of bowel obstruction was seen (Figure 1). A pelvic ultrasonogram (USG) was conducted on the second presentation which was normal. The patient’s pain had improved with simple analgesia on both occasions and she was discharged home from the emergency department on simple analgesia and oral aperients, with a presumed diagnosis of constipation. On the third occasion the patient presented with worsening of the cramping abdominal pain associated with nausea and vomiting. The pain was more severe than on previous occasions and localized to the epigastric region and left upper quadrant. She was vomiting food particles and not passing gas. Her last menstrual period was one week prior to presentation. On examination she was afebrile but tachycardic with a heart rate of 104/min, blood pressure of 115/60 mmHg and oxygen saturation of 97% on room air. On auscultation her heart sounds were normal and lungs were clear. Abdominal examination showed a distended abdomen with generalized tenderness which was worse in the epigastrium, without guarding or rebound tenderness. No masses were felt. Bowel sounds were present. Rectal examination found an empty rectum. Vaginal examination showed no evidence of adnexal tenderness nor was pain elicited with palpation at the fornices. The patients bloods showed a raised C-reactive protein of 62 mg/L (normal <3 mg/L) and a hemoglobin that had dropped from 15.4 g/dL to 11.7 g/dL in the last one week. Peripheral blood smear and and routine blood tests were normal. An abdominal computed tomography (CT) scan with oral and intravenous contrast was performed which confirmed a small bowel obstruction possibly secondary to adhesions (Figure 2 A, B). There was bowel dilatation in the mid to distal small bowel where the bowel was 5.2 cm in diameter. No evidence of any obstructing mass was noted and no lymphadenopathy was visualized. The transition point of the obstruction was not obvious. The rest of the study was normal in appearance. The provisional diagnosis by the surgical team was a small bowel obstruction but the cause was not clear and acute appendicitis could not be excluded. The decision was made to perform an emergency diagnostic laparoscopy. On laparoscopy the major abnormality was adherence of the distal small bowel to the pelvis. The operation was converted to a lower midline laparotomy. There was a stenotic and fibrosed terminal ileum and cecum which were adhering to the sigmoid colon, right ovary and uterus due to a brown nodule. Most of the cecum and some of the mesenteric fat was noted to be hemorrhagic and fibrotic with adhesions. There were multiple inflamed lymph nodes in the mesentery of the bowel. Within the cecum there was a protrusion of mucosa about 20x12x9 mm. It was unclear whether this picture was due to a neoplasm, inflammatory bowel disease or endometriosis. The ileum and cecum were dissected of the pelvic structures and the terminal ileum and cecum were divided. Twenty cm of the terminal ileum and 15 cm of the right colon were resected, adhesions were divided and a primary anastamosis was performed. Histological examination of the resected ileum showed focal areas of superficial mucosal ulceration with destruction of glands and a neutrophilic infiltrate (Figure 3 A, B). Granulomas were not seen. Sections taken from the strictured ileum showed the presence of endometrial glands and stroma on the serosal surface of the bowel, extending into the outer half of the muscularis propria. There was associated fibrosis, scarring and distortion of the wall and the overlying mucosa. There was no evidence of dysplasia or malignancy. The area of polypoidal mucosa within the cecum appeared to be the mouth of the appendix which was also associated with endometriosis, fibrosis and scarring and had completely intussuscepted into the cecum. The diagnosis made was endometriosis with associated inflammation and stricture formation involving the distal ileum, appendix, cecum, ascending colon, omental fat and associated lymph nodes. Post- laparotomy our patient made an unremarkable recovery and was discharged home. She was followed up in the surgical outpatients clinic after two ...