Deep pelvic endometriosis: a radiologist's guide to key imaging features with clinical and histopathologic review

Deep pelvic endometriosis causing ureteral obstruction

Endometriosis is a chronic disease characterized by the presence and growth of endometrial glands and stroma outside of the uterine cavity. The pathogenesis is unclear, but a common theory attributes the condition to retrograde menstruation into the peritoneal cavity via the fallopian tubes. Hormonal influence causes these ectopic tissues to undergo cyclical bleeding, resulting in subsequent inflammation and scar tissue formation; however, it can affect postmenopausal women. In rare instances, endometriotic lesions can obstruct the ureter and result in hydroureteronephrosis and subsequent loss of renal function. This condition presents with nonspecific symptoms and is known as an often-silent disease, resulting in challenging and delayed preoperative diagnosis. In this article, we report the case of an asymptomatic 65-year old female who was diagnosed with deep pelvic endometriosis, which obstructed the right distal ureter. We focus on optimizing diagnosis and management through the application of radiological imaging modalities, specifically computed tomography (CT) and magnetic resonance imaging (MRI).

'That's just the Ovary!' and other cases of mistaken identity on CT of the female pelvis

CT is often the first imaging test in female patients with lower abdominal and pelvic pain because of the wide availability of CT and differential diagnoses that span both gynecologic and gastrointestinal disease. Pathology within the female pelvis may be difficult to diagnose on CT owing to suboptimal delineation of anatomy in comparison to MRI and ultrasound. These challenges are confounded by overlapping imaging features of a wide range of gynecologic entities and can lead to diagnostic dilemmas. High value CT interpretation will direct the clinician to the best next diagnostic step as ultrasound and MRI provide superior soft tissue delineation. Other imaging modalities, laboratory investigations, or tissue sampling may be necessary to definitively characterize indeterminate lesions. In this review, we illustrate various cases of mistaken identity on CT of the female pelvis involving the ovaries, uterus, and peritoneal cavity while highlighting clinical pearls that may aid the radiologist in arriving at the correct diagnosis and avoiding potential pitfalls.

Endometriosis in the Cecum: A Rare Clinical Entity

Cecal endometriosis is uncommon and may mimic other tumors of the colon, making it difficult to safely diagnose preoperatively. We report a case of a 50- year-old female who was found to have a cecal lesion during an endoscopic examination, which was performed for the investigation of anemia. It was also confirmed by conducting a computed tomography (CT) scan. Due to the high possibility of this mass identification as a neoplasm, the patient underwent a laparoscopic right hemicolectomy with an extracorporeal side-to-side isoperistaltic anastomosis. However, the postoperative histological diagnosis of the mass was cecal endometriosis, as the histopathology report noted endometrial tissues in the submucosa and muscolaris propria of the ileocecal region. Endometriosis of the cecum is a rare manifestation and can often be misdiagnosed as a malignant tumor. Further research is required, concerning preoperative characteristics of bowel masses in women, in order to provide optimal operative treatment and avoid unnecessary invasive procedures.

Conservative vs radical bowel surgery for endometriosis: A systematic analysis of complications

BACKGROUND

Endometriosis of the bowel can be associated with significant morbidity. Surgery to remove it carries risks. Options include conservative shaving or discoid resection and more radical segmental bowel resection.

AIMS

To determine if more conservative shaving or discoid bowel resection is associated with fewer risks than more radical segmental resection.

MATERIAL AND METHODS

This study is a systematic review. We considered eligible any cohort, observational or randomised controlled trial (RCT) study of at least ten women per arm comparing conservative vs radical bowel surgery for endometriosis. We divided complications into two groups, major and minor. One additional article was added due to its significance in answering our study question as well as the high quality of the study design as an RCT.

RESULTS

There were 3041 studies screened. Eleven studies were included (n = 1648). For major complications, the risk ratio for shaving and disc excision vs segmental resection is 0.31 (95% CI 0.21-0.46), while the risk difference is -0.25 (95% CI -0.41 to 0.10). For minor complications, the risk ratio is 0.63 (95% CI 0.36-1.09), while the risk difference is -0.03 (95% CI -0.12 to 0.05).

CONCLUSIONS

Conservative shaving or discoid excision surgery is associated with reduced complications. Previous studies demonstrated a trend toward this finding, but suffered from relatively low participant numbers, increasing the risk of type one statistical error. Our results allow surgeons to make informed choices about potential complications when deciding how to approach bowel endometriosis. The results also allow patients to have more information about the risks. However, outcomes in the studies analysed are heterogenous and are from low-quality evidence.

Infiltrating endometriosis: diagnostic keys in abdominal ultrasonography

OBJECTIVE

Endometriosis is the presence of endometrial tissue outside the uterus. Endometriosis of the bowel and urinary tract are types of extragenital endometriosis that manifest with nonspecific symptoms, but their detection involves specific therapeutic strategies. Although the characteristics of the disease on transvaginal ultrasonography and on magnetic resonance imaging have been described in many publications, few references describe its characteristics on abdominal ultrasonography. This paper illustrates the findings for infiltrating endometriosis involving the bowel and urinary tract on abdominal ultrasonography and shows the usefulness of this technique for identifying signs of the disease that have been described with other techniques. Knowledge of infiltrating endometriosis and its ultrasonographic features will enable radiologists to suggest its diagnosis and to include it in the differential diagnosis of pelvic pain in women of child-bearing age.

CONCLUSION

Abdominal ultrasonography is a useful tool in the diagnosis of extragenital endometriosis. Familiarity with the ultrasonographic appearance of this entity facilitates the diagnostic orientation and management of patients with pelvic pain.

Genitourinary manifestations of endometriosis with emphasis on the urinary tract

Endometriosis is a common benign condition affecting women. The disease has a broad spectrum of presentations from incidental lesions in asymptomatic women to causing significant and debilitating morbidity in others. Ectopic endometrial glands are located in predictable locations throughout the pelvis, including implantation on the ovaries and in the rectouterine cul-de-sac. Less commonly, the urinary tract may be involved. As genitourinary manifestations may remain symptomatically occult or masquerade as other diagnoses, it is essential for the radiologist to be aware of the imaging features, consider this diagnosis, and potentially save the patient from delayed treatment.

Encyclopedia of endometriosis: a pictorial rad-path review

Endometriosis affects approximately 10% of reproductive age women and represents a significant cause of pelvic pain and infertility. Unfortunately, the diagnosis of endometriosis is often delayed by years. Endometriosis may manifest as cystic lesions in the ovaries known as endometriomas. Superficial endometriosis is typically detected by laparoscopy along the pelvic peritoneum as these lesions tend to be difficult to detect by imaging. Deep infiltrative endometriosis may be detected by ultrasound, CT or MRI in classic locations within the pelvis, such as the posterior cul-de-sac and uterosacral ligaments. Endometriosis may also involve the thorax, gastrointestinal and urinary tracts, and locations such as the abdominal wall and abdominal organs. We present MRI and CT case examples, together with corresponding laparoscopic and histopathology images to enhance radiologists' understanding of this disease.

Comparison of routine pelvic US and MR imaging in patients with pathologically confirmed endometriosis

PURPOSE

To estimate the benefit of pelvic magnetic resonance (MR) imaging after routine pelvic ultrasound (US) in patients with pathologically or surgically proven endometriosis.

METHODS

Patients with surgically or pathologically proven endometriosis who had routine pelvic US followed by pelvic MR within 6 months prior to surgery were included. Patients were excluded if they had previously confirmed endometriosis, pregnancy, or surgery > 6 months after MR. The detection rate of endometriosis by pelvic US and MR was compared to the surgical/pathological reference standard.

RESULTS

83 female patients (mean age 40 ± 9) met inclusion criteria and had surgical/pathological confirmation of endometriosis. The mean time interval between pelvic US and MR was 33 ± 43 days, with 64 ± 69 days between MR examination and surgery. US detected endometriosis in 22% (18/83) of patients compared to 61% (51/83) for MR (p < 0.0001). 51% (33/65) of patients with a negative pelvic US exam had a positive MR. MR identified additional sites or sequela in the majority of patients with a positive US (14/18; 78%), including extraovarian locations [e.g., fallopian tubes 7/18 (39%), uterus 7/18 (39%), uterine ligaments 6/18 (33%), posterior cul de sac 5/18 (28%), pelvic side walls 5/18 (28%), abdominal wall 1/18 (6%)] and sequela [ovarian tethering 5/18 (28%), 6/18 (33%) bowel adhesive disease, posterior cul de sac obliteration 2/18 (11%), hydrosalpinx 2/18 (11%), and hydronephrosis 1/18 (6%)]. 3 T MR detected endometriosis in 33/46 (72%) patients compared to 18/37 (49%) for 1.5 T MR (p = 0.03).

CONCLUSION

Pelvic MR imaging had a higher detection rate of surgically/pathologically proven endometriosis and provides more information about disease location and sequela compared to routine pelvic US.

Imaging of gastrointestinal endometriosis: what the radiologist should know

Deep invasive gastrointestinal endometriosis (DIGIE) is a frequent and severe presentation of endometriosis. Although most cases invade the rectosigmoid colon, DIGIE can involve any portion of the gastrointestinal tract from the stomach to the rectum, and is commonly multifocal and multicentric. Although histopathologic confirmation with surgery remains the gold standard for diagnosis, ultrasound (US) and magnetic resonance imaging (MRI) are the key non-invasive imaging modalities for initial assessment. US may be preferred as a screening study because of its easy availability and low-cost. Pelvic MRI and magnetic resonance enterography (MRE) provide substantial advantages for disease mapping in the pre-operative period, particularly in extensive bowel endometriosis. Although medical management of DIGIE with hormonal therapy can help control symptoms, disease course can be relentless and require surgical intervention. Surgical options depend on, the location; length; depth; circumference; multicentric or multifocal disease. With procedures including simple excision, fulguration of superficial lesions, shaving, disc excision, and segmental resection. A successful treatment outcome is largely dependent on good communication between the treating surgeon and the radiologist, who can provide vital information for effective surgical planning by reporting the key elements that we elaborate upon in this paper.

Suspensory Ligaments of the Female Genital Organs: MRI Evaluation with Intraoperative Correlation

The uterus, which plays an important role in the reproductive process, provides a home for the developing fetus and so must be in a stable, though flexible, location. Various structures with suspensory ligaments help provide this berth. MRI with high spatial resolution allows us to detect and evaluate these relatively fine structures. Under physiologic conditions, MRI can be used to depict uterine and ovarian ligaments (ie, the uterosacral, cardinal, and round ligaments, as well as the suspensory ligament of the ovary). In the presence of pathologic conditions (inflammation, endometriosis, tumors), the suspensory ligaments may appear thickened or invaded, which makes their delineation easier. Understanding the normal anatomy of the suspensory ligaments of the female genital organs and using a standardized nomenclature are essential for identifying and reporting related pathologic conditions. The female pelvic anatomy and the suspensory ligaments of the female genital organs are described as depicted with MRI. Also, the compartmental anatomy of the female pelvis is explained, including the extraperitoneal pelvic spaces. Finally, a checklist is provided for structured reporting of the MRI findings in the female pelvis. Online supplemental material is available for this article. ^©RSNA, 2018.

Intestinal obstruction caused by endometriosis: Endoscopic stenting and expedited laparoscopic resection avoiding stoma. A case report and review of the literature

INTRODUCTION

Endometriosis is the growth of endometrium outside the uterine cavity. In 5-15% of cases the disease can affect the colon and small bowel, causing complete obstruction and requiring resection in about 1% of cases.

CASE SUMMARY

We describe a case of sigmoid obstruction due to endometriosis in a 38 years old woman with personal history of endometriosis. She was admitted for abdominal pain and constipation. The patient was treated with endoscopic stenting and subsequent laparoscopic sigmoidectomy.

DISCUSSION

Bowel obstruction caused by endometriosis is a rare event. Its diagnosis can thus be a clinical and radiological challenge but it may be suspected in all young woman with colonic obstruction. At present, the management of endometriosis is an integrate approach of both medical and surgical therapy. In case of irreversible colonic obstruction surgery is mandatory. The treatment of choice is usually an emergency procedure (either Hartmann procedure or resection and anastomosis with stoma placement). This approach entails all the risks related to emergency procedures and can have important psychological and biological drawbacks.

CONCLUSION

Endoscopic prosthesis placement as bridge to surgery is a feasible therapeutic strategy in colonic obstruction due to endometriosis. It brings about all the advantages of an expedited one step laparoscopic surgical procedure. Laparoscopic elective resection has a lower rate of stoma placement and has a postoperative pregnancy rate grater than open surgery.

Cecal Endometriosis With Intestinal Metaplasia Misdiagnosed as Neoplasm of the Cecum by Intraoperative Histological Examination

Appendiceal or cecal endometriosis with intestinal metaplasia is uncommon and may mimic mucinous tumors of the appendix. A 50-year-old woman was found incidentally to have an ileocecal lesion. In the intraoperative histological examination, a diagnosis of neoplasm of the cecum was made predominantly based on mucin extrusion with scattered lining mucinous epithelium. However, postoperative histological diagnosis of the lesion was cecal endometriosis with intestinal metaplasia as determined by thoroughly microscopic inspection and the presence of typical endometrial glands with surrounding endometrial-type stroma. There was no evidence of recurrence and pseudomyxoma peritonei after 1 year of follow-up. Overinterpretation of cytological atypia or mucin extrusion in endometriosis may lead to inappropriate surgical management. Therefore, in any ileocecal or appendiceal lesions with mucinous epithelia and mucin extrusions, removal of sufficient tissue from different portions of the lesion is essential for surgeons and pathologists to make a precise diagnosis in the intraoperative histological examination.

Bowel endometriosis: a diagnostic and therapeutic challenge

Bowel endometriosis is the most common extragenital manifestation of endometriosis. Clinical suspicion is of utmost importance for achieving its diagnosis. Management of this condition is, however, always challenging to the gynaecologist. We report a case of bowel endometriosis in which the patient presented with dyschezia and haematochezia prior to her menses for the past 2 years. A 44-year-old para two woman presented with worsening dysmenorrhea and dyspareunia. She also experienced dyschezia and haematochezia prior to her menses for the past 2 years. An examination revealed a fixed retroverted uterus. A computed tomography scan showed focal bowel thickening. She underwent a colonoscopy examination and biopsy that revealed stromal endometriosis. She was subsequently treated with dienogest and became asymptomatic. Diagnosis and management of this debilitating illness was revisited and discussed.