A 48-year-old woman presented with a 3 day history of diffuse colicky abdominal pain relieved by vomiting without other associated symptoms. Examination revealed a distended abdomen with diffuse tenderness. Blood tests were remarkable for a raised white cell count only. Her abdominal film showed a small bowel obstruction and abdominal computed tomography (CT) showed significant terminal ileal stricturing consistent with Crohn’s disease (fig 1). She commenced intravenous steroids and oral 5-aminosalicylates and her symptoms resolved entirely. Colonoscopy with terminal ileal intubation was macroscopically and histologically normal.

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Figure 1

Computed tomography scan of the abdomen showing thickened loops of terminal ileum with significant luminal narrowing, likely to be consistent with Crohn’s disease.

Not satisfied that a clear diagnosis of inflammatory bowel disease was made, we tapered and discontinued the patient’s medications, and followed her closely as an outpatient. She was re-admitted 4 weeks later with recurrent abdominal pain. Exploratory laparoscopy showed terminal ileal inflammation and stricturing, and she had a terminal ileal resection. Histological analysis showed classical appearance of endometriosis involving the small bowel (fig 2). The patient made an excellent recovery.

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Figure 2

Immunohistochemistry staining showing glandular tissue staining positive (using PR Novocastra Lot L606428) for progesterone receptors within terminal ileum consistent with diagnosis of small bowel endometriosis.

Up to 30% of patients with endometriosis may have involvement of the gastrointestinal tract,1 with large bowel involvement in the majority of cases.2 Sole involvement of the terminal ileum is rare and may present with small bowel obstruction.3 Despite advances in radiology and endoscopy, it remains a difficult diagnosis to make. This is further complicated by the possibility of both pathologies occurring in the same patient.4 The cyclic nature of the symptoms, as occurred with this patient, may provide clues to the diagnosis. Although hormonal therapy might be considered, surgical intervention is optimal for definitive management of small bowel disease.