Correlation between findings of nuclear magnetic resonance and 3D anorectal ultrasound in patients with suspected deep endometriosis / Correlação entre achados de ressonância magnética nuclear e ultrassonografia anorretal 3D em pacientes com suspeita de endometriose profunda

Abstract Introduction: Endometriosis is defined as endometrial glands and stroma that occur outside the uterine cavity. Although not malignant, ectopic endometrial tissue and the resulting inflammation can cause dysmenorrhea, dyspareunia, chronic pain, and infertility. The diagnostic imaging tests most used are nuclear magnetic resonance imaging (NMR) and ultrasonography (USG). Methods: Correlate the findings of three-dimensional anorectal ultrasound with the NMR findings of the pelvis with intestinal preparation in women with deep endometriosis, through a retrospective, observational, cross-sectional study, evaluating 63 female patients with suspected deep endometriosis with probable involvement intestinal. The evaluation period was from March 2016 to April 2018. Statistical analysis was performed using the kappa agreement to assess the degree of agreement between 3D NMR and USG in relation to the degree of infiltration in the rectal muscle layer, with a confidence interval of 0.272-0.579, p < 0.001. Results and conclusion: According to the results presented, three-dimensional anorectal ultrasonography proved to be a good diagnostic test in the evaluation of the middle and posterior compartments of deep lesions of endometriosis, and there was a correlation between the NMR findings of the pelvis with intestinal preparation in relation to injuries that invade the muscularis propria of the rectum.

Resumo Introdução: A endometriose é definida como glândulas endometriais e estroma que ocorrem fora da cavidade uterina. Embora não maligno, tecido endometrial ectópico e a inflamação resultante podem causar dismenorreia, dispareunia, dor crônica e infertilidade. Exames de diagnóstico por imagem mais utilizados são Ressonância Nuclear Magnética e ultrassonografia. Métodos: Correlacionar os achados da ultrassonografia anorretal tridimensional com os achados da ressonância magnética nuclear de pelve com preparo intestinal em mulheres portadoras de endometriose profunda, através de um estudo retrospectivo, observacional, transversal, avaliou 63 pacientes do sexo feminino com suspeita de endometriose profunda com provável acometimento intestinal. O período de avaliação foi Março de 2016 a Abril de 2018. Foi realizada análise estatística por meio do Coeficiente de Concordância de Kappa para se avaliar o grau de concordância entre RNM × USG 3D em relação ao grau de infiltração na camada muscular retal com cálculo de intervalo de confiança de 0,272-0,579; p < 0,001. Resultados e conclusão: Segundo os resultados apresentados a ultrassonografia anorretal tridimensional mostrou-se um bom exame diagnóstico na avaliação dos compartimentos médio e posterior de lesões profundas de endometriose e há correlação entre os achados da ressonância magnética nuclear de pelve com preparo intestinal em relação a lesões que invadem a muscular própria do reto.

Endometriosis ileal. Causa infrecuente de obstrucción intestinal en mujeres en edad fértil / Ileal endometriosis. An uncommon cause of bowel obstruction in women in fertile age

Resumen La endometriosis se define como la presencia de tejido endometrial fuera de la cavidad uterina. Ocurre en aproximadamente 5 a 10% de las mujeres en edad fértil. Cuando afecta al intestino tiende a confundirse clínicamente con una gran variedad de afecciones por lo cual en algunas oportunidades se le ha llamado también "la gran simuladora". La revisión de la literatura muestra que la localización intestinal es poco frecuente y que la obstrucción secundaria a esta causa es aún más inusual, siendo el diagnóstico preoperatorio un desafío para los cirujanos. Con el propósito de resaltar características clínicas y de estudio por imágenes que ayuden a la sospecha preoperatoria de esta entidad tan infrecuente en la práctica habitual, se presentan dos casos de mujeres operadas de urgencia, sin diagnóstico previo de endometriosis y con oclusión intestinal como primera manifestación de la enfermedad. El tratamiento consiste en la resección intestinal del sector afectado y anastomosis primaria. El diagnóstico se basa en un alto índice de sospecha y debería ser considerado en mujeres en edad fértil, sin antecedentes patológicos y con historia de menstruaciones dolorosas.

Abstract Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity. It affects ~5-10% of women in their reproductive years. When it affects the intestine, it tends to be confused clinically with a wide variety of affections, which is why it has sometimes been called "the great simulator". A review of the literature shows that intestinal localization is rare and that obstruction secondary to this cause is even more unusual, with preoperative diagnosis being a challenge for surgeons. With the purpose of highlighting clinical and diagnostic imaging characteristics that help the preoperative suspicion of this entity, so rare in routine practice, we present two cases of women who underwent emergency surgery, without a previous diagnosis of endometriosis and with intestinal occlusion as the first manifestation of the disease. Treatment of intestinal occlusion by endometriosis consists of intestinal resection of the affected sector and primary anastomosis. Diagnosis of intestinal occlusion secondary to ileal endometriosis is based on a high index of suspicion and should be considered in women of childbearing age, without a history of disease and with a history of painful menstruation.

Intestinal endometriosis: a diagnostic dilemma

Background: Endometriosis is a benign gynaecological condition that causes significant morbidity to women of reproductive age group. It uncommonly affects the gastrointestinal tract and acute bowel obstruction is a rare manifestation.Methods: A retrospective observational study was conducted on eight patients.Results: In three patients (37.5%), small intestinal involvement was seen, and colon was involved in five patients (62.5%). One (12.5%) patient presented with complete bowel obstruction while in others partial obstruction of the intestine was seen.Conclusions: Intestinal endometriosis is a diagnostic challenge and should be considered in young menstruating women with gastrointestinal symptoms. Intestinal endometriosis is the most common extra-pelvic site and it is found in 12% of women with endometriosis. The true incidence of endometriosis causing bowel obstruction is unknown. Pre or intraoperative sigmoidoscopy may prove helpful in ruling out malignancy. The gold standard for diagnosis is laparoscopy and biopsy, which allows a full assessment of the pelvis as well as surgical resection if required. The management of endometriosis is an integrated approach of both medical and surgical therapy. Bowel resection is usually undertaken if there are features of obstruction or bleeding, and if there is suspicion of malignancy.

Intestinal perforation due to deep infiltrating endometriosis during pregnancy: case report / Rotura intestinal durante a gravidez devido a endometriose profunda infiltrativa: relato de caso

Abstract We report the case of a 33 year-old woman who complained of severe dysmenorrhea since menarche. From 2003 to 2009, she underwent 4 laparoscopies for the treatment of pain associated with endometriosis. After all four interventions, the pain recurred despite the use of gonadotropin-releasing hormone (GnRH) analogues and the insertion of a levonorgestrel intrauterine system (LNG-IUS). Finally, a colonoscopy performed in 2010 revealed rectosigmoid stenosis probably due to extrinsic compression. The patient was advised to get pregnant before treating the intestinal lesion. Spontaneous pregnancy occurred soon after LNG-IUS removal in 2011. In the 33rd week of pregnancy, the patient started to feel severe abdominal pain. No fever or sings of pelviperitonitis were present, but as the pain worsened, a cesarean section was performed, with the delivery of a premature healthy male, and an intestinal rupturewas identified. Severe peritoneal infection and sepsis ensued. A colostomy was performed, and the patient recovered after eight days in intensive care. Three months later, the colostomy was closed, and a new LNG-IUS was inserted. The patient then came to be treated by our multidisciplinary endometriosis team. The diagnostic evaluation revealed the presence of intestinal lesions with extrinsic compression of the rectum. She then underwent a laparoscopic excision of the endometriotic lesions, including an ovarian endometrioma, adhesiolysis and segmental colectomy in 2014. She is now fully recovered and planning a new pregnancy. A transvaginal ultrasound (TVUS) performed six months after surgery showed signs of pelvic adhesions, but no endometriotic lesions.

Resumo Relatamos o caso de uma mulher de 33 anos que apresentava de dismenorreia grave desde a menarca. Entre 2003 e 2009, a paciente foi submetida a quatro laparoscopias para o tratamento de dor associada à endometriose. A dor persistiu apos as 4 cirurgias apesar do uso de análogos do hormônio de liberação de gonadotropina (GnRH) e da inserção de um sistema intrauterino de levonorgestrel (SIU-LNG). Finalmente, uma colonoscopia realizada em 2010 revelou estenose rectosigmoide, provavelmente devido à compressão extrínseca. A paciente foi aconselhada a engravidar antes de tratar a lesão intestinal. A gravidez espontânea ocorreu logo após a remoção de LNGIUS em 2011. Na 33ª semana de gestação, a paciente começou a sentir dor abdominal intensa, sem febre ou sinais de peritonite. Como a dor piorou consideravelmente, a paciente foi submetida à cesariana com nascimento prematuro de um menino saudável. Durante a cesárea foi identificado rotura intestinal com peritonite grave e sepse. Uma colostomia foi realizada, e a paciente admitida no centro de terapia intensiva por 8 dais. A colostomia foi fechada e um novo SIU-LNG inserido. A paciente passou a ser tratada pela nossa equipe multidisciplinar de endometriose. A avaliação diagnóstica revelou a presença de lesões intestinais com compressão extrínseca do reto. Foi então submetida a uma excisão laparoscópica das lesões endometrióticas, incluindo umendometrioma ovariano, adesiólise e colectomia segmentar em 2014. Ela está agora totalmente recuperada e planeja nova gravidez. Uma ultrassonografia transvaginal (TVUS) realizada seis meses após a cirurgia revelou sinais de aderências pélvicas sem lesões de endometriose.

Presentación de un paciente con endometriosis del canal anal / Presentation of a Patient with Endometriosis of Anal Canal

Se realizó una presentación de una paciente atendida en el Hospital General Universitario Vladimir Ilich Lenin de Holguín, de 35 años de edad, que desde el año 2002 (hace 14 años) comenzó a presentar dolor rectal y perineal, relacionados con la defecación y esfuerzo físico, acompañado de dismenorrea, constipación, y dispareunia, manifestando un aumento de estos síntomas durante el periodo menstrual, refiriendo escaso alivio con el uso de analgésicos. Por los datos del examen físico se encontró una tumoración extramucosa en la pared anterolateral derecha del canal anal, de aproximadamente 3 cm de diámetro, blanda, poco movible y ligeramente dolorosa al tacto. No se informaron datos de interés en los exámenes de laboratorio. La ecografía y rectosigmoidoscopia, resultaron normales. Se realizó resección de la tumoración con adecuada evolución postquirúrgica y desaparición de los síntomas. En el estudio histológico se informó la existencia de células endometriales en el tejido intestinal, confirmándose el diagnóstico de endometriosis en el canal anal.

A case report was presented at “V. I. Lenin” Provincial Teaching University Hospital of a 35-year-old female patient who has been suffering from rectal and perianal pain related to defecation and physical effort since 2002 (fourteen years ago). It was accompanied by dysmenorrheal, showing an increase of the symptoms during the menstrual period. She said that there was no relief of the pain with analgesic. The physical examination showed an extra mucosa soft tumor at the right anterolateral wall of the anal canal of approximately 3 cm diameter, with few movements and slightly painful on palpation. Lab tests showed no interesting facts. Ecography and rectumsigmoidoscopy did not show any alteration. The tumor was resected with an adequate post operatory evolution. The symptoms disappeared. The histological study showed endometrial cells in the intestinal tissue, confirming the endometriosis of the anal canal diagnosed.

Endometriosis extrapélvica semejando cáncer colorrectal estenosante: Reporte de dos casos / Colorectal cancer endometriosis resembling stenosing extrapelvic: Report of two cases

Presentamos a dos mujeres -de 40 y 42 años- con endometriosis colorrectal, ambas con antecedente de endometriosis pélvica y episodios de rectorragia simultáneos con la menstruación. En las evaluaciones endoscópicas detectamos una tumoración sigmoidea y una tumoración rectosigmoidea respectivamente, que aparentaron corresponder a cáncer colorrectal estenosante de origen epitelial.

We present two women of 40 and 42 years with colorectal endometriosis, both with a history of pelvic endometriosis and simultaneous episodes of rectal bleeding with menstruation. In endoscopic evaluations detected a sigmoid tumor and rectosigmoid tumor respectively, which apparently corresponds to stenosing colorectal cancer of epithelial origin.

Intestinal Endometriosis Mimicking Carcinoma of Rectum and Sigmoid Colon: A Report of Five Cases

Among women with intestinal endometriosis, the sigmoid colon and rectum are the most commonly involved areas. Sometimes, the differential diagnosis of colorectal endometriosis from carcinoma of the colon and rectum is difficult due to similar colonoscopic and radiologic findings. From October 2002 to September 2007, we performed five operations with curative intent for rectal and sigmoid colon cancer that revealed intestinal endometriosis. Colonoscopic and radiologic findings were suggestive of carcinoma of rectum and sigmoid colon, such as rectal cancer, sigmoid colon cancer and gastrointestinal stromal tumor (GIST). Anterior resection was performed in two patients, low anterior resection was performed in one patient and laparoscopic low anterior resection was done in two patients. We suggest to consider also intestinal endometriosis in reproductive women presenting with gastrointestinal symptoms and an intestinal mass of unknown origin.

Complete colonic obstruction secondary to endometriosis: A case report

This is the case of a 39 year old female who underwent an urgent laparotomy because of gut obstruction. Intraoperative impression was rectosigmoid carcinoma with frozen pelvis and assessed to be unresectable. hence a transverse colostomy was done. Although subsequent endoscopic and CEA evaluations gave the impression of intestinal endometriosis, malignancy could not be ruled out. Patient was started on Danazol and when it became ineffective, surgical control was contemplated. CT scan of the abdomen was done to assess for possible presence of abdominal malignancy and with a negative report, patient underwent abdominal subtotal hysterectomy, bilateral salpingo-oophorectomy, segmental resection of the rectosigmoid and appendectomy. Transverse colostomy was closed later. The objective of this paper was to report a case of complete rectosigmoid obstruction secondary to endometriosis, in order to demonstrate the difficulty in establishing an accurate diagnosis and the propensity of colonic endometriosis to mimic colon cancer.

Endometriosis como causa de obstrucción intestinal: reporte de caso / Endometriosis as a cause of bowel obstruction: case report

La obstrucción del intestino delgado es una de las patologías quirúrgicas abdominales más frecuentes atendidas por los cirujanos en los servicios de urgencias. Se trata de un síndrome con múltiples causas; una particularmente interesante es la endometriosis intestinal, la cual ocurre hasta en el 37% de 1as pacientes con esta patología. Sin embargo, la mayoría no experimenta síntomas relacionados con el tracto gastrointestinal.Presentamos el caso de una mujer de 40 años de edad, con obstrucción intestinal secundaria a esta entidad, la cual requirió resección quirúrgica con anastomosis primaria. La evaluación patológica demostró endometriosis extensa del intestino delgado, que producía estenosis completa del lumen intestinal. Este informe reporta una de las raras, aunque significativas complicaciones de la endometriosis extrapélvica: la obstrucción intestinal. De ahí que, la endometriosis del tracto digestivo, debe incluirse en el diagnóstico diferencial de aquellas pacientes con obstrucción intestinal, que se encuentren en edad reproductiva.

Intestinal obstruction is one of the most frequent abdominal surgical pathologies assisted by the surgeons at emergency services. It involves a multifactorial syndrome, being one of particular interest, intestinal endometriosis, which accounts to almost 37% of patients with this entity. However, the majority does not present gastrointestinal symptoms.We present the case of a 40 year old female, with obstruction due to this pathology, who required surgical resection with primary anastomosis intestinal. The histopathological evaluation revealed extense endometriosis of small intestine, with total stenosis of the lumen. This work reports one uncommon but significative complication of extra pelvic endometriosis: intestinal obstruction. Hence, the endometriosis of digestive tract should be included in the differential diagnosis of those patients with intestinal obstruction; in between reproductive age.