The authors report the case of a 34-year-old woman who presented with acute mechanical intestinal obstruction of the small bowel due to the migration of a necrotic subserosal myomatous nodule into the ileal lumen through a uteroileal fistula in a uterus with multiple myomas. The nodule was discovered incidentally during an emergency exploratory laparotomy for acute intestinal obstruction in a previously undiagnosed abdomen. Treatment consisted of extraction of the myomatous nodule from the ileal lumen and ileal resection followed by an end -to-end ileoileal anastomosis. Several uterine myomas were removed, followed by resection of the migrating myoma's compartment. The postoperative course was uneventful, with a return of bowel function on the third postoperative day. Microscopic analysis of the migrated nodule revealed a leiomyoma. The migration of a myomatous nodule adds to the list of causes of mechanical occlusion by intraluminal obstruction in women of childbearing age.

Acute intestinal obstruction is a frequent and serious medical and surgical emergency [ 1,2]. It is one of the most common acute abdominal injuries, requiring emergency surgical admission and generally associated with a high mortality rate, estimated at 30% in sub-Saharan Africa [3,4]. Its severity stems from several factors, including the formation of a third fluid space in the intestinal lumen upstream of the obstruction, leading to electrolyte disturbances and the development of intestinal ischemic lesions [3]. It is primarily characterized by three functional signs: abdominal pain, vomiting, and the absence of bowel movements and gas, and one physical sign: abdominal distension in cases of lower obstruction.

Two main etiological groups of mechanical intestinal obstructions are described: strangulation obstructions and obstruction obstructions [6,7]. Obstruction can be of parietal, extraluminal, or intraluminal origin. Intraluminal causes are most often represented by accidentally swallowed foreign bodies, intestinal worms, and the migration of a gallstone [8]. While hernias and volvulus are common causes of intestinal obstruction [9,10] in sub-Saharan Africa, intraluminal intestinal obstruction due to the migration of a uterine myoma is extremely rare. We report the first case at the University Hospital of Brazzaville.

Observation (Presentation Case)

Ms. MC, 34 years old, was admitted to the emergency department of the Brazzaville University Hospital on November 10, 2022, for abdominal pain. The clinical picture dated back to November 6, 2022, four days prior to her admission, for progressive, intense, intermittent periumbilical abdominal pain, described as a feeling of heaviness, unrelieved by usual analgesics. This was associated with vomiting of food followed by bile, with an absence of bowel movements and gas. This clinical picture necessitated her emergency consultation at the Brazzaville University Hospital. The patient is A nulliparous woman, followed in the Gynecology department for primary infertility due to a uterine myoma with multiple myomas, was examined. She was conscious and in fairly good general condition with a fever of 38.5° C. Her conjunctival mucosa showed good color and she was hemodynamically stable (blood pressure: 120/60 mmHg; pulse: 80 bpm). She presented with abdominal distension, peritoneal irritation with abdominal guarding, and a recurrent umbilical and pouch-like tenderness. An abdominal X-ray revealed air-fluid levels that were wider than they were tall, centrally and peripherally oriented, consistent with a small bowel obstruction (Photo 1).

                                                Photo 1: Rx ASP frontal view, standing (air-water levels) Emergency Department.The pelvic ultrasound performed as part of the infertility assessment had revealed a uterus with polymyomas before the occlusive episode. Laboratory tests revealed leukocytosis (WBC: 18,810/mm³) and anemia (Hb: 8 g/dL). An abdominal and pelvic CT scan could not be performed. A diagnosis of febrile bowel obstruction was therefore made. An exploratory laparotomy was indicated and performed urgently after brief resuscitation. During the procedure, the following were observed: a clean abdominal cavity; distension of the small intestine proximal to a rounded mass adjacent to the ileocecal valve; a uterus with multiple myomas; and a loop of the terminal ileum closely adhered to the uterine fundus 30 cm from the ileocecal valve. Adhesiolysis of the ileum revealed a utero-ileal fistula with two openings: ileal (photo 2) and uterine (photo 3).

                                                                                         Photo 2: Ileal opening Photo 3: Uterine opening

We performed delivery of the intraluminal mass through the ileal orifice (Photo 5) followed by ileal resection and then end -to -end ileo-ileal anastomosis (Photo 6) after anterograde drainage of the small bowel through the fistulous orifice of the ileum.

This mass, measuring 4 centimeters in diameter, is a myomatous nodule undergoing necrobiosis.

Microscopic examination of the nodule revealed a benign connective tissue tumor proliferation made up of non-atypical leiomyocytes arranged in crisscrossing and intertwined bundles corresponding to a leiomyoma (photo 4)

                                                                                               Photo 4: Microscopy of the uterine leiomyoma

                                                 Photo 5: Delivery of the nodule.               Photo 6: Ileo-ileal anastomosis. myomatous through the ileal opening

The second operative stage consisted of a resection of the uterine compartment of the migrated myoma, followed by the removal of several myomas (photo 7).

                                                                                               Photo 7: Myomectomy specimens

After abdominal lavage, a drain was placed in the pouch of Douglas before closure of the abdominal wall. Antibiotics, analgesics, a blood transfusion, and oxytocin completed the surgical treatment. The postoperative course was uneventful. The drain was removed on the third postoperative day. The patient was discharged from the hospital on the sixth day, two days after the return of bowel function.

Obstructions encountered in our practice and in African settings are most often caused by tumors in the bowel wall. In more than 90% of cases, these are malignant tumors predominantly located in the colon [11]. Purely luminal causes in the small bowel are related to a foreign body, or, although rare, the migration of a gallstone [ 8, 12].

A large uterus with multiple myomas can indirectly cause intestinal obstruction through extrinsic compression [13]. Obstruction due to migration of a myoma is exceptional. Inflammatory phenomena related to necrobiosis of the myomatous nodule lead to adhesion of the intestine and omentum to this myoma, thus forming a true plastron. The consequence is the formation, by contiguity, of a uteroileal fistula. This fistula allows the migration of this nodule into the intestinal lumen.

The size of the myoma prevented it from passing through the ileocecal valve, thus obstructing the lumen of the terminal ileum and causing the obstruction. Conversely, a small nodule would be eliminated with the stool through the anus without the patient noticing.

The etiological diagnosis of any mechanical occlusion is made preoperatively by means of medical imaging, in particular abdominal computed tomography with high diagnostic performance [1, 14]. This procedure could not be performed urgently in our setting due to the 

unavailability of the necessary equipment. Had it been performed, it would have revealed a well-circumscribed, rounded or oval, dense image within the uterine lumen, without definitively confirming its myomatous nature. The observed necrobiosis is a relatively rare complication of uterine myomas. It is an ischemic necrosis, initially aseptic. This complication often occurs in pregnant women with myomas [15]. This myoma was likely superinfected. However, superinfection is an unusual feature of uterine leiomyomas [15]. It is assumed to be due to bacterial colonization of the leiomyoma. In order to limit the spread of the infection, physiologically, the omentum and the loops of the small intestine adhered to the myoma, which over time was phagocytosed by an ileal loop, thus justifying its intraluminal migration.

Among the causes of mechanical occlusions by obstruction in women of childbearing age, the possible intraluminal intestinal migration of a necrotic uterine myoma must also be noted.

The authors declare no conflict of interest.